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TABLE OF CONTENTS
PAGE

MATERNAL MORTALITY 2

MECHANISM OF LABOUR 11

PARTOGRAPH & DYSFUNCTIONAL LABOUR 20

MONITORING IN LABOUR 29

CARDIOPULMONARY RESUSCITATION 43

ANTEPARTUM HAEMORRHAGE 48

POSTPARTUM HAEMORRHAGE 52

BLOOD COMPONENTS & TRANSFUSION 64

RETAINED PLACENTA 70

UTERINE INVERSION 74

SHOULDER DYSTOCIA 79

BREECH & EXTERNAL CEPHALIC VERSION 89

TWIN PREGNANCY 96

CORD PROLAPSE 100

INSTRUMENTAL DELIVERY 103

HYPERTENSIVE DISORDERS OF PREGNANCY 112

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MATERNAL MORTALITY
Objectives

 Know the definition of maternal deaths.

 Understand the common causes of maternal death in Malaysia and Sarawak.

Introduction
The national objective is to reduce the maternal mortality to less than 20/100,000 LB. For
Sarawak, with the present coverage of health facilities at one health clinic for an area of
631.7 sq. km (ranging from 1:98.9 in Samarahan district to 1:3880.6 in Belaga district),
and the professional to population ratio of 1:16,032.1 (ranging from 1:4175 in Daro
district to 1:32,300 in Meradong district), this objective is a challenge to achieve.

Definition
Maternal deaths
Maternal death has been defined as the death of a woman while pregnant or within 42
days of termination of pregnancy, irrespective of the duration and site of pregnancy, from
any cause related to or aggravated by the pregnancy or its management, and from other
causes not related to or caused by the pregnancy

Direct maternal Death

Deaths resulting from obstetric complications of the pregnant state (pregnancy, labour
and puerperium) from interventions, omissions, incorrect treatment or from a chain of
events resulting from any of the above.

Indirect maternal death

Deaths resulting from previous existing disease or disease that developed during
pregnancy and which was not due to direct obstetric causes but which was aggravated by
the physiologic effects of pregnancy.

Fortuitous death
Deaths from other causes not related to or influenced by pregnancy, which happen to
occur in pregnancy or the puerperium.

Maternal Mortality Rate

Maternal mortality rate (MMR) is the number of women who die from pregnancy related
causes during pregnancy and within 42 days of childbirth, per 100,000 live births.
 Excluding accidental or incidental causes
 Illegal immigrants are not included although each case is investigated
 MMR = No of women dies
100,000 live births

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Millennium Developmental Goals (MDG 5)

Aim to improve maternal health

Target 5A
Reduce maternal mortality ratio by three quarters, between 1990 and 2015.

Target 5B
Achieve, by 2015, universal access to reproductive health.

Trend from 1990 - 2015

Globally, Maternal Mortality Ratio fell by 44% with estimated MMR 216 maternal death
per 100000 live births from 385 per 100000 live births. Hence, the target of reducing
Maternal Mortality Ratio by 75% has not been achieved globally.

For Malaysia, National MMR has been plateauing for the past 10 years. MDG5 Target
for Malaysia is to achieve MMR of 11.08/100000 live births. According to the latest
CEMD report, National MMR was 25.4 in 100000 live births in 2011. Therefore,
achieving MDG5 is still a huge milestone for our country.

Sustainable Development Goal (SDG)

SDG is the continuous global effort in reducing MMR and ultimately ending preventable
maternal deaths. The target 3.1 of SDG 3 includes reducing MMR to < 70 in 100000 live
births by 2030.

Trend of maternal mortality in Malaysia

Malaysia has witnessed a significant reduction in maternal mortality rate (MMR) from
540 per 100,000 live births (LB) in 1950 to 139 in 1970. The decline has continued but
plateaued at around 27/100,000 LB from 2002 to 2005 as shown in from the graph below.

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Trend of maternal mortality in Sarawak

There is marked reduction of MMR in the state of Sarawak. The trend of MMR for the
past 9 years are as below:

YEAR MMR ( per 100,000

live births)

2008 30.8

2009 37.0
2010 26.7
2011 25.4
2012 26.6
2013 9.3 (*achieve MDG 5
target)
2014 16.0
2015 16.0
2016 7.3

Confidential Enquires into Maternal Death

Confidential Enquires into Maternal Deaths (CEMD) involve surveillance into maternal
deaths with primary intention to identify all the maternal deaths, analyze causes and
contributors to maternal deaths at all levels of mother’s care. Key features of CEMD is
confidentiality, which means the identity of women, health care workers involved
remained anonymous. It is a process involving investigations at all levels of care for a
women, from which consensus on the cause of death and contributors to maternal death is
being made. CEMD report will include key recommendations derived from the enquiries
and report will be disseminated so that remedial actions can be put into practice to reduce
maternal death.

CEMD Report 2009 - 2011

Executive Summary

1. 834 pregnancy related deaths were reported from 2009 – 2011.

2. Maternal Mortality ratio in 2011 was 25.4 per 100000 live births.

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3. Principal cause of maternal deaths were Medical Disorders in Pregnancy, Obstetric

embolism, and Hypertensive Disorders in Pregnancy.

4. More than 60% of the maternal deaths occurred during the postnatal period.

5. The risk of maternal death was higher in woman aged more than 40 years and in
mothers who were multiparous.

Key Recommendations

Efforts on stepping up the quality of maternal healthcare services are the main focus in
reducing maternal death.

Pre-pregnancy care should be provided for women with pre-existing medical conditions

Early intervention and treatment can reduce the incidence of maternal complications and
to optimize the women’s health before embarking a pregnancy in high risk women.
Greater effort should be made to provide family planning services to high risk women.

Ectopic pregnancy should be ruled out in any woman in the reproductive age who
complains of abdominal pain.

Cardiologist should be involved in the management of pregnant woman with heart

disease under combined care.

There should be more centres with echocardiogram service made accessible to the
medical officers to refer pregnant patient for echocardiogram when in doubt and will be
of convenience to the pregnant patients logistically.

Senior doctors and specialist should be involved in the care of patients with medical
conditions.

Regular obstetric drills should be organized for health staff managing obstetric patients.

All high risk patients in pregnancy and postpartum period should be offered
thromboprophylaxis. A national audit of the compliance to thromboprophylaxis
guidelines in all obstetric units should be developed.

Postnatal nursing should focus on the ability to exclude presence of Deep Vein
Thrombosis and postnatal depression.

Health personnel should be trained to identify psychiatric disorders, domestic violence,

substance abuse or self-harm during pregnancy and postnatal period.

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There is a need to build up the capacity of the health staffs in the hospitals and health
clinics, of the current updates in the care of pregnant women throughout the pregnancy
and postnatal.

Existing referral system should be strengthened though supervision and communication.

Obstetric protocols, guidelines and manuals must be available in all labour rooms and
obstetric units.

All home deliveries must be conducted by trained health personnel.

Hospital staff must inform the health clinic when patients are discharged.

Home visits and defaulter tracing must be done by health staff.

Practice of universal precaution at all time when managing patients with systemic
infection.

Pregnant women are considered ‘at clinical risk’ from seasonal influenza and are
therefore eligible to receive Influenza vaccination and antiviral medications.

Prevention of teenage pregnancy could be addresses through better policies, improved

education and information campaigns, as well as programs to reach adolescents in
schools, communities or wherever they may be.
Road safety should be part of antenatal education especially in the use of helmets and
seat belts.

Postmortem examination should be offered in all pregnancy related deaths when cause of
deaths was in doubt and family members should be fully advised about the process of
postmortem.

Statistic from CMED Report 2009 - 2011

Number of maternal deaths and classification

CLASSIFICATION 2009 2010 2011

Direct 103(47.2%) 101 (41.7%) 97 (39.9%)
Indirect 51 (19.4%) 45 (18.6%) 33 (13.6%)
Subtotal 154 146 130
MMR 31.0 26.7 25.4
Fortuitous 94 (37.9%) 96 (39.7%) 100 (43.5%)
Grand total 248 242 230

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MMR according to state

STATES 2009 2010 2011

Death MMR Death MMR Death MMR

Perlis 0 0 2 48.6 0 0

Kedah 13 36.4 12 34.2 7 19.5

P.Pinang 5 22.2 8 37.8 4 17.9

Perak 10 27.3 10 27.8 8 21.3

Selangor 34 33.5 26 26.4 24 23.1

K.Lumpur 8 30.9 6 28.6 3 11.8

Putrajaya 0 0 0 0 0 0

N.Sembilan 2 11.7 8 47.2 7 39.6

Melaka 0 0 2 15.4 7 50.1

Johor 17 29.8 15 26.8 15 27.5

Pahang 7 27.0 10 38.5 11 36.9

Terengganu 8 33.6 9 37.1 6 24.2

Kelantan 14 39.4 9 25 9 23.9

Sabah 20 38.4 18 33.3 17 30.9

Labuan 0 0 0 0 1 57.7

Sarawak 16 37.0 11 26.7 11 25.4

Malaysia 154 31.0 146 29.7 130 25.4

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Causes of maternal death

CAUSES 2009 2010 2011

PPH 20 (13.0%) 11 (7.5%) 19 (14.6%)

HPT DISORDER 18 (11.7%) 25 (17.1%) 25 (19.2%)

OBSTETRIC 23 (14.9%) 30 (20.5%) 16 (12.3%)

EMBOLISM
MEDICAL 51 (33.1%) 46 (31.5%) 37 (28.5%)
ILLNESS
APH 4 (2.6%) 3 (2.1%) 3 (2.3%)

PUERPERAL 6 (3.9%) 6 (4.1%) 2 (1.5%)

SEPSIS
ABORTION 7 (4.5%) 2 (1.4%) 2 (1.5%)

ECTOPIC 4 (2.6%) 7 (4.1%) 4 (3.1%)

UNSPECIFIED 5 (3.2%) 0 0
COMPLICATION
OF
PREGNANCY &
PUERPERIUM
ASSOCIATED 0 0 1 (0.8%)
WITH
ANAESTHESIA
OTHERS 6 (3.9%) 2 (4.1%) 3 (2.3%)

TOTAL 154 146 130

Postpartum haemorrhage has been one of the major cause of maternal death for the past
few years. In 2009 – 2011, proportion of death due to associated medical conditions was
high throughout the years, ranged from 28.5% - 33.1%. Obstetric embolism comes
second followed by hypertensive disorder in pregnancy and postpartum haemorrhage.

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Maternal death by Parity Specific

PARITY 2009 2010 2011

Primigravida 32 43 45

Multiparity 97 64 56

Grandmultipara 25 39 29

Maternal death by Family Planning Practice

FAMILY 2009 2010 2011

PLANNING

Ever user 38 (24.7%) 29 (19.9%) 40 (30.8%)

None user 114 (74.0%) 86 (58.9%) 65 (50.0%)

Don’t know 2 (193%) 31 (21.2%) 25 (19.2%)

TOTAL 154 146 130

Maternal death by Stage of Pregnancy

STAGE OF PREGNANCY 2009 2010 2011

Antenatal 42 (27.3%) 54 (37.0%) 43 (33.1%)

Intrapartum 14 (9.1%) 7 (4.8%) 1 (0.8%)

Postpartum 91 (59.1%) 83 (56.8%) 84 (64.6%)

Early pregnancy deaths 7 (4.5%) 2 (1.4%) 2 1.5%)

TOTAL 154 146 130

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Maternal death by Colour Coding

COLOUR 2009 2010 2011

CODING

Red 13 (8.4%) 12 (8.2%) 12 (8.2%)

Yellow 18 (11.7%) 26 (17.8%) 17 (13.1%)

Green 50 (32.5%) 44 (30.1%) 49 (37.7%)

White 10 (6.5%) 4 (2.7%) 9 (6.9%)

No information 63 (40.9%) 60 (41.1%) 43 (33.1%)

TOTAL 154 146 130

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MECHANISM OF LABOUR AND MANAGEMENT OF

NORMAL LABOUR

Objective

 Understand the mechanism of normal labour.

 Able to establish the diagnosis of labour
 Understand management of normal labour

Introduction
The mechanism of labour is the passive way in which the fetus makes its way through the
birth canal. The movements allow the fetus to negotiate the changing dimensions of the
mother’s pelvis.

The widest diameter of pelvic brim is the transverse, whereas the widest diameter of the
pelvic outlet is the anteroposterior (AP). The movement therefore allows the best
utilization of space within the pelvis.

Pelvic inlet

Pelvic outlet

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The widest diameter of the fetal head enters the pelvis in the transverse position and
rotates to emerge in the anteroposterior diameter at the pelvic outlet. The shoulders
similarly follow the rotation.

The commonest presentation is the vertex and the commonest positions are either left or
right occipitoanterior. The following description describes a left occipitotransverse (LOT)
or left occipitoanterior (LOA) position.

The series of changes in position and attitude which the fetus undergoes during its
passage through the birth canal includes:
1) Descent
2) Flexion
3) Internal rotation
4) Extension
5) Restitution
6) External rotation
7) Delivery of the body

Descent
Descent starts before labour, as the fetal head becomes engaged. In primigravida, descent
occurs at around 36 weeks (when the fetal head starts to engage). In multigravidae
engagement may not occur until labour commences. Further descent occurs during
labour.

Flexion
When labour starts the fetal head will be in a position of natural flexion. As the fetal head
descent, lateral pressure from the birth canal cause increased flexion of the fetal head.
This increased flexion facilitates its passage from the pelvic brim into the circle of the
pelvic cavity.

Head still floating. Not yet descended Descend and flexion of the head
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Internal rotation
As labour continues the fetal head meets the resistance of the pelvic floor and the occiput
rotates forward from the LOT or LOA position to lie under the suprapubic arch, with the
sagittal suture lying in the AP diameter. The rotation occurs because as the well flexed
head, with the occiput leading, meets the sloping gutter of the levatores ani, their shape
directs the occiput anteriorly (OA).

Internal rotation causes the head to

become OA position.
Note that the shoulders are not rotated

Extension
The head then delivers by extension. Once the occiput has passed below the symphysis
pubis, the head extends with the nape of the neck pressed firmly against the pubic arch.
Thus as extension continues the forehead, face and chin deliver over the perineum.

Extension of the fetal head and

crowning.

Crowning occurs around this stage - When the largest diameter of the fetal head distends
the introitus.
At this stage, the fetal head no longer recedes between contractions.

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Restitution
As internal rotation occurs the fetal head becomes twisted a little on the shoulders
(remember that the shoulders did not rotate like the head during internal rotation). As
soon as it is delivered it resumes its natural position, with respect to the shoulders. This is
called restitution.

External Rotation
At delivery of the head the shoulders lie in the oblique position. With continued descent
they rotate to bring the bisacromial diameter into the anterioposterior diameter of the
pelvic outlet. Rotation of the shoulders occurs as the right and anterior shoulder is lower
than the left and meets the resistance of the pelvic floor before the left, it therefore rotates
to the space in front. This causes the head to rotate so that the occiput lies next to the left
maternal thigh. This is external rotation.

Delivery of the body

The anterior shoulder is now able to pass under the pubis and with lateral flexion of the
body the posterior shoulder is born. The rest of the body then follows easily.

Normal labour
Definition of normal labour
Labour starts with regular contractions which are progressively in intensity and
frequency, resulting in progressive cervical effacement and dilatation.

It is important to establish the correct diagnosis of labour as wrong diagnosis of labour

will result in unnecessary intervention (e.g. ARM), unnecessary admission and wrong
diagnosis of prolonged latent phase.

Labour process is considered a stress to mother and fetus. It needs appropriate level of
care and monitoring.

Stages of labour

1st stage
From the start of labour to full dilatation of cervix. It can be divided into latent and active
phase.
 Latent phase – start of labour to cervical dilatation of up to 4 cm
 Active phase – from cervical os of 4 cm to full dilatation
Acceptable rate of progress during active phase of 1st stage of labour should be 0.5 – 1
cm/H.

2nd stage
From full dilatation to delivery of baby. According to Intrapartum Care from NICE
guideline 2014:
 Second stage of labour can be divided into passive and active stage

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 In nulliparous
o Birth expected to occur within 3 hours of active stage
o Diagnose delay if delivery does not occur after 2 hours of active stage
o Suspect delay if no progress of labour after 1 hour of active stage and
offer assessment
 In multiparas
o Delivery should occur after 2 hours of active stage
o Diagnose delay if active stage is more than 1 hour
o Suspect delay if no progress of labour after 30 minutes of active stage
and offer assessment

*Nevertheless, in our setting where there is lack of facilities or expertise to manage

complication of prolonged second stage, it is advisable to diagnose delay of second
stage after 1 hour of active pushing in nulliparous and 30 minutes in multiparas.

3rd stage
From delivery of baby to delivery of placenta. 3rd stage can be managed physiologically
when placenta is allowed to separate spontaneously without oxytocic drug and cord
clamping. However, we advocate practice of active management of 3rd stage as it is
associated with less blood loss.
Practice active management of third stage of labour:
 Routine use of uterotonic drugs
 Controlled cord traction (CCT) after signs of separation of placenta
 Deferred cord clamping
o Do not clamp the cord earlier than 1 minute from the birth of baby unless
there is concern about the baby’s wellbeing
o Clamp the cord before 5 min in order to perform CCT
Prolonged third stage of labour is diagnosed when placenta is not delivered within 30
minutes from delivery of baby. (Refer to chapter of Retained Placenta)

Principles of management of labour

1. Initial assessment
2. Close monitoring of maternal and fetal condition
3. Adequate pain relief
4. Adequate hydration
5. Diagnosis and intervention of abnormal labour
6. Emotional support/supportive companion

Initial assessment
Upon admission to labour ward, patient should be assessed to define her risk. Assessment
includes:
1. Review of antenatal card for antenatal coding and risk factors as well as significant
previous antenatal history
2. General assessment of the patient – BP, pulse rate, temperature, pain score

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3. Abdominal examination and vaginal examination

Risk assessment determines the degree of monitoring needed and the level of care that
patient needs.
*High risk case will need input from an obstetrician.

Maternal and fetal monitoring

Maternal monitoring
 Blood pressure 4 hourly (more frequent in hypertensive disorders)
 Temperature 4 hourly
 Pulse rate hourly
 Frequency of Contractions half-hourly and pain score
 Urine output and urine ketone 4 hourly
 Vaginal examination 4 hourly
 Patient’s wishes, expectations and concerns

Fetal monitoring
 Normal / low risk patients: Intermittent auscultation with handheld doppler
ultrasound (daptone) or intermittent cardiotocogram (CTG) 4-6 hourly during latent
phase of labour.
o Once in active phase of labour, monitor fetal heart rate every 15-30 minutes.
(If daptone is used, perform auscultation during and immediately after
contraction for at least 1 minute).
 High risk patients : continuous CTG monitoring
All parameters of monitoring are recorded into partograph. In high risk patient, SOS chart
may be needed to record all parameters of maternal monitoring.

Immediate attention is required in any of the following observations:

1. BP of ≥ 140/90 mmHg in non- 1. Any abnormal presentation

hypertensive patient 2. Abnormal lie
2. Pulse rate ≥ 120 bpm 3. Floating head per abdomen
3. Temperature of ≥ 38°C 4. Anhydramnios
4. Proteinuria in non-hypertensive 5. Polyhydramnios
patient 6. Suspicious or abnormal fetal heart
5. Any fresh vaginal bleeding rate
6. Rupture of membranes more than 24 7. Presence of significant meconium
hours
7. Pain that differs from normal
contraction (high suspicion for uterine
rupture)

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Adequate analgesia
Every woman in labour should NOT be denied the right for analgesia in labour. Child
birth is a normal life event and yet it is considered one of the most painful experience to a
woman.

Maternal pain and stress has deleterious effects on fetus. Maternal hyperventilation from
pain and stress will cause respiratory alkalosis and results in shift of oxygen dissociation
curve to left. This will reduce oxygen transfer to fetus and cause fetal metabolic acidosis.
Similarly, maternal pain and stress stimulates release of catecholamines and cortisol,
which causes uterine vessels vasoconstriction and thus, decreases the placental blood
flow.

Pain relieve modalities can be pharmacological or non-pharmacological

Non-pharmacological methods
Can be used as an adjunct to severe labour pain. They are often inexpensive, easy to
institute and low risk. However, there is only poor quality evidence supporting their
effectiveness in reducing moderate to severe labour pain.

Shown to be effective Continuous one-to-one support

May be effective Music/music assisted relaxation techniques
Birthing ball/upright position
Water immersion
Relaxation technique/massage
Insufficient evidence of effectiveness Biofeedback
Hypnosis
Aromatherapy

Pharmacological methods
Pharmacological methods include:
1. Inhalational – nitrous oxide (Entonox)
2. Opioid
3. Non-opioid
4. Regional analgesia

1. Inhalational analgesia (Entonox)

a. Mixture of inhaled nitrous oxide plus oxygen in 1:1 ratio
b. Short half-life: 2 – 3 min; cleared rapidly via lungs
c. Does not interfere with endogenous oxytocin; therefore, it is unlikely to affect
the labour process or spontaneous vaginal rate
d. Maternal adverse effects
i. Lightheadedness
ii. Nausea and vomiting
iii. Hallucination
iv. Hyperventilation
v. Tetany
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e. Crosses placenta rapidly; does not affect fetal heart rate or respiratory rate in
newborn
f. Evidence of effectiveness: lower pain score but more side effects

2. Opioids
a. Intramuscular injection of pethidine – most commonly used
b. Maternal side effects
i. Drowsiness
ii. Hypoventilation
iii. Urine retention
iv. Nausea/vomiting
v. Increase in gastrointestinal transit time
c. Fetal effects
i. It crosses placenta by passive transfusion
ii. Causes changes in fetal heart rate – decreased variability
d. In neonate
i. It may take up to 6 days to eliminate pethidine from neonate’s
system
ii. It causes respiratory depression, hypothermia, poor feeding, altered
crying and decreased alertness
e. Management of depressed neonate
i. Intramuscular Narcan 0.2 cc to the newborn (0.01 – 0.02 mg/kg)
ii. Dose can be repeated in 3 – 5 min
iii. Monitor infant for 1 hour after Narcan is given
f. Effectiveness
i. There is a large systemic review which includes 57 studies
ii. Opioid analgesia provides some effectiveness compared to placebo
iii. But it is associated with significant maternal and fetal adverse
effects
g. Patient-controlled analgesia (PCA) – remifentanil PCA
i. Can be offered as an alternative if regional analgesia is
contraindicated
ii. Remifentanil is rapidly acting synthetic opioid; rapidly
metabolized with half-life of 3 minutes
iii. Potentially cause nausea, vomiting and maternal pruritus
iv. There are safety issues of respiratory depression (32%) with 5%
encounter oxygen saturations of < 90%; therefore, monitroing of
maternal oxygen saturation is mandatory

3. Regional analgesia
a. Gold standard for pain relief in labour
b. Includes
i. Epidural
ii. Combined spinal epidural
iii. Spinal

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c. No women should be denied regional analgesia on basis of stage of labour

and/or relative/spouse
d. Maintenance regimens
i. Intermittent midwifery top-ups
ii. Patient-controlled epidural pump (PCEA)
iii. Continuous infusion with or without PCEA – available in Sarawak
General Hospital
e. Maternal adverse effects
i. 1:140000 risk of paraplegia or death
ii. Prolonged second stage
iii. Increased instrumental delivery
iv. No associated with increased risk of prolonged first stage,
caesarean section or long term back problem
f. Fetus
i. Improved acid-base status
g. Care/monitoring when using epidural analgesia
i. Intravenous access prior to commencement of regional analgesia
ii. Routine preloading and maintenance fluid is not mandatory
iii. BP monitoring every 5 minutes for 15 minutes during the
establishment or after further boluses
iv. Anaesthetic review after 30 minutes if the woman if not pain free
v. Continuous electronic fetal monitoring for 30 minutes during the
establishment or after further boluses

Adequate hydration
Good hydration is important for satisfactory labour progress. Assessment of hydration
status should be carried out regularly. The assessment should include measuring of urine
volume and checking urine ketones.

Women in labour should be allowed low residual diet or fluids except for high risk cases.
Low risk cases should be allowed to ambulate without intravenous drip.

Diagnosis and intervention of abnormal labour

Refer to the next chapter for management of abnormal labour

Emotional support/supportive companion

Companionship/continuous one-to-one support has been shown to be effective non-
pharmacological way of analgesia in labour. It has proven to reduce analgesia
requirements, reduce instrumental delivery and lower rates of dissatisfaction with
childbirth.

It is the role of health care provider, especially midwives to provide continuous support
to women in labour with positive attitude. Husband/partner’s companionship is equally
important, if not superior.

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PARTOGRAPH AND DYSFUNCTIONAL LABOUR

Objectives

 To understand about partograph and how to plot a partograph.

 Able to identify abnormal labour and manage accordingly

Partograph
A partograph is a diagrammatic representation of the progress of labour. It is where all
observations of the patient and her fetus are charted in a manner which facilitates
monitoring of the progress of labour by the health care worker. The main components
that need to be monitored and plotted on the partograph are:
 The progress of labour
 Maternal condition
 Fetal condition

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Important: The World Health Organization (WHO) has produced a new partograph
which is essentially the same with the previous partograph with a few important
differences:
 The new partograph does not have the “latent phase” period anymore.
 Active phase of labour starts at 4cm of os dilatation

The following text will be based on the new partograph.

Using a partograph
The information charted on a partograph is as follows:

 Patient information
Name, gravida, parity, registration number, diagnosis/ problem list.

 Fetal heart rate

This is recorded every half an hour and more frequently in high risk cases.

 Membrane and amniotic fluid

The state of the membrane and amniotic fluid (liquor) should be documented as
follows:
I : Membrane intact
C : Clear liquor
M : Meconium-stained liquor
B : Blood-stained liquor

 Moulding
Moulding of the fetal skull is recorded as follows:

0 : No moulding
1 : Sutures opposed
2 : Sutures overlapped but reducible
3 : Sutures overlapped and not reducible
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 Cervical dilatation
This is marked with a cross (X), and plotting is begun on the partograph when the
pt has reached 4cm (active phase of labour) or ARM has been done for IOL.

 Descent of fetal head

This is marked with an (O) and is used to show the station during vaginal
examination. (-2, -1, 0, +1, +2)

 Alert line
The alert line starts at a cervical dilatation of 4cm. It increases to the point of
expected full dilatation at a rate of 1 cm per hour. If the progress of labour is
normal, this progress line (cervicogram) on the partograph will correspond with
the alert line or lie to the left of it.

 Action line
The action line is parallel to the alert line and can be 1 to 4 hours to the right of
the alert line. In Sarawak General Hospital, a 4-hour action line is observed.

 Hours
This charts the time (in hours) elapsed since the onset of the active phase of
labour.

 Time
The actual time is recorded.

 Contractions
Uterine contractions are assessed every half an hour and charted as the number of
contractions in 10 minutes and duration of contraction in seconds. The duration of
contraction reflects the strength of the contraction.

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Quantification of uterine contraction by clinical palpation.

 Oxytocin
The amount of oxytocin added per volume of IV fluid and the rate of infusion
must be recorded every half an hour.

 Additional drug
Any additional drugs given such as pethidine and metoclopramide must be
recorded at the time of administration.

 Maternal pulse rate.

This is documented every half hour with a dot.

 Maternal BP
This is recorded every 4 hours (unless more frequently indicated) and marked
with arrows.

 Maternal temperature
This is recorded every 2 hours.

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 Urine protein, ketone and volume

Each time the patient passes urine or is catheterized, the urine volume should be
measured and recorded. The urine is tested for protein and ketone and the results
documented.

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When all of the parameters are charted, this is the whole partogram:

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When to start a partograph?

When the patient is in active phase of labour, i.e. at cervical os of 4cm

Abnormal partograph
The following features in the partograph indicate poor progress of labour:
 The rate of cervical dilatation is less than 0.5 – 1 cm/H
 Cervical dilatation at or beyond the action line

Diagnosis of poor progress of labour

1. False labour
In false labour, the cervix remains undilated, and uterine contraction remains
impalpable or infrequent. No further action needs to be taken in the absence of other
complications.
Misdiagnosis of false labour or prolonged latent phase leads to unnecessary
induction of labour or augmentation, which may fail. This may lead to
unnecessary Caesarean Section or chorioamnionitis.

2. Prolonged latent phase

Cervical dilatation remains 3 cm or less despite 8 hours of regular contraction. The
duration may be longer for primigravidae.

3. Primary dysfunctional labour

The rate of cervical dilatation less than 1cm/ hour in the active phase of labour due to
ineffective uterine contractions (usually less than 3 in 10 minutes, each lasting less
than 40 seconds)

4. Cephalopelvic disproportion (CPD)

Secondary arrest of cervical dilatation and descent of the presenting part occurs
despite good uterine contractions. This can be either:

 Absolute – Due to big fetus or small pelvis or both.

 Relative – Due to fetal malposition.

Evidence of obstructed labour

 Secondary arrest of cervical dilatation and descent of presenting part

 Large caput
 Third degree moulding
 Presenting part poorly applied to cervix
 Oedematous cervix
 Ballooning of lower uterine segment
 Formation of retraction band (Bandl ring)
 Maternal/ fetal distress

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Management of abnormal partograph

General management of an abnormal partograph includes the following:
 Rapid evaluation of the condition of the woman and her fetus and provision of
supportive care.
 Assess hydration status and test urine for ketones – Hydrate with IV fluids if the
woman is dehydrated or urine ketone is positive.
 Review partograph to look for clues to the cause(s) of the poor progress of labour.

Management of abnormal partograph at the level of health centre/clinic

1) Prolonged latent phase

The patient must be transferred to a hospital for further action.

2) Moving to the right of the alert line

In the active phase of labour, plotting of cervical dilatation will normally remain
on, or to the left of the alert line (i.e. progress of labour should be at least 1
cm/hour). However, some will cross to the right of the alert line and this warns
that labour may be prolonged.

When this occurs in the absence of adequate facilities for obstetric emergency and
operative delivery, the woman must be transferred to a hospital where such
facilities are available.

3) At or beyond the action line

If a woman’s labour reaches or crosses this line, a decision must be made about
the cause of poor progress, and appropriate action taken. This decision and action
must be taken in a hospital with facilities to deal with obstetric emergency and
operative delivery.

Management of abnormal partograph at the level of hospital with facilities for

operative delivery

1) Prolonged latent phase

The patient should be carefully assessed to rule out false labour. If the evidence
support prolonged latent phase the options is either conservative management
with closer monitoring or labour may be augmented. If the os remains less than 4
cm dilated after amniotomy and 8 hours of oxytocin infusion, caesarean section
should be considered.

2) Moving to the right of alert line

If membranes are intact, perform amniotomy. If contractions remain inefficient
after amniotomy (primary dysfunctional labour), augment the contractions with
oxytocin.

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3) At or beyond the action line

If the cause is thought to be CPD, proceed to caesarean section. However, if CPD
has been ruled out and contractions are found to be inefficient, consider
augmentation with oxytocin, provided there is no fetal or maternal distress.

Inefficient contractions are less common in multigravidae than in

primigravidae. Hence, every effort should be made to rule out CPD in
multigravidae before augmenting with oxytocin.

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MONITORING IN LABOUR – FETAL HEART RATE AND

UTERINE ACTIVITY

Objectives

 Understand the modalities of fetal monitoring in labour

 Able to interpret cardiotocograph (CTG) tracing in a systematic way with the
mnemonic of DR C BRaVADO.
 Able to categorize CTG according to standard guidelines
 Understand the underlying causes/pathophysiology of CTG abnormalities
 Achieve competence in managing abnormal CTG
 Understand the importance of risk management and proper documentation

Intermittent Fetal heart rate (FHR) monitoring

The goal for FHR monitoring is to detect signs that warn potential adverse events in order
to provide intervention in a timely manner. The FHR can be monitored by intermittent
auscultation or by electronic means with an external or internal device.

Auscultation of fetal heart rate

In addition to the use of the electronic fetal monitor, auscultation of the FHR may be
performed with a stethoscope, Pinard stethoscope or doppler ultrasound device (i.e.
daptone). Auscultation is a learned skill that improves with practice.

Pinard stethoscope

If the stethoscope is used, the end should be turned so that the domed side of the
stethoscope, rather than the flat side, is open to the connective tubing to the ear pieces.
The domed side is then placed on the maternal abdomen.

The fetoscope should be applied to the listener’s head because bone conduction amplifies
the fetal heart sound for counting. It is the ventricular fetal heart sound that can be
counted with stethoscope or fetoscope.

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The doppler ultrasound device transmits ultra-high frequency sound waves to the moving
interface of the fetal heart valves and deflects these back to the device, converting them
into an electronic signal that can be counted.

How to auscultate fetal heart rate.

Procedure
1 Perform Leopold’s manoeuver by palpating
the maternal abdomen
2 Place the listening device over the area of
maximum intensity, which is usually over the
back of the fetus, and clarity of the fetal heart
sound
3 Count the maternal radial pulse
4 Palpate the abdomen for the absence of
uterine activity
5 Count the FHR for 30 to 60 seconds between
contractions
6 Auscultate the FHR during contraction, if
possible, and for 30 seconds after the end of
the contraction
7 When there are distinct discrepancies in FHR
during or between listening periods,
auscultate for a longer period during, after
and between contraction
Rationale
To identify fetal presentation and
position
To obtain the clearest and loudest
sound, this is easier to count.
To differentiate it from the fetal
rate
To be able to count FHR between
contraction
To identify the basal heart rate
(BHR) which can only be assessed
during the absence of uterine
activity
To identify the FHR during the
contraction and as a response to
the contraction
To identify changes from the
baseline that indicate the need for
another mode of FHR monitoring

Frequency of auscultation
Regardless of the method used to assess FHR, the standard practice is to evaluate and
record the heart rate at specific intervals. The frequency of auscultation and
documentation of the FHR is based on the AAP/ACOG guidelines (1997) and SOGC
standards (1995).

Frequency of auscultation

Stage of labour Low risk High risk

Latent phase Every 30-60 minutes Every 30 minutes
Active phase Every 30 minutes Every 15 minutes
Second stage Every 15 minutes Every 5 minutes

Based on the reviews of well-conducted studies, no differences in perinatal outcome have

been identified between intermittent auscultation and continuous electronic FHR
monitoring. This has been observed even in the presence of risk factors on admission or
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those appearing during the course of the labour, when the FHR has been evaluated at the
intervals describe above.

FHR monitoring should be performed at regular interval. In addition, the FHR should
also be auscultated:
a. Before
i. Administration of medications (including oxytocics and analgesics)
ii. Period of ambulation
iii. ARM
b. Following
i. Rupture of membrane
ii. Changes in the strength of the contractions
iii. Vaginal examination
iv. Changes in the dosage of oxytocin
v. Response to the oxytocics
vi. Response to any medication

Documentation
Documentation of the FHR must be accompanied by other routine parameters that are
assessed during labour, including uterine activity, maternal observation and assessment,
and both maternal and fetal responses to intervention. It should be noted how long the HR
was auscultated and whether this was before, during or after a uterine contraction. The
rate, rhythm and abrupt or gradual increase or decrease of the FHR during any part of the
auscultation should be described in relationship to the concurrent uterine activity.

Interpretation of the auscultated FHR

a. Reassuring FHR
FHR in the normal heart rate range without wide fluctuation from the average range

b. Non-reassuring fetal heart rate

i. A baseline FHR of < 110 beats per minute (bpm) or > 160 bpm
ii. A decrease in FHR during of following a contraction
iii. Irregular cardiac rhythm

Management options of a non-reassuring fetal heart rate

a. Increase frequency of auscultation
b. Apply electronic fetal heart rate monitoring (CTG)
c. Intervene appropriately to promote uterine and umbilical blood flow, improve fetal
oxygenation and decrease uterine activity if excessive
d. Notify health care provider as appropriate.

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Electronic fetal monitoring

There are two modes of electronic monitoring. The external or indirect mode employs the
use of an external transducer placed on the maternal abdomen to assess FHR and uterine
activity. The internal or direct mode uses a spiral electrode to assess the FHR and
variability and the intrauterine pressure catheter to assess uterine activity and intrauterine
pressure.

The electronic fetal monitor is called cardiotocograph (CTG) and the tracing that it
produces is called cardiotocogram.

The term “cardio” refers to the heart (in this case, the fetal heart) and the term “toco”
refers to the uterine contractions.

Fetal heart
trace

CTG

Uterine
contractions

Overall interpretation of CTG

There should be a systematic way of interpretation of CTG. The mnemonic of “DR C
BRAVaDO” encourages attending health care workers to approach CTG in a systematic
and standardized way. It
a. Encourages an assessment of risk prior to attempting interpretation,
b. Takes into account the interpretation of contraction tracing before the heart rate
tracing, and
c. Allows the attending clinician to achieve an overall conclusion on the CTG

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Remember : Examples
DR C BRAVaDO

Fetus – IUGR, oligohydramnios, congenital abnormalities,

DR Define Risk meconium-stained liquor, etc.
Mother – DM, HPT, postdates, previous caesarean, etc.

C Contractions Good contractions : 3-4 contractions (>40s)

BR Baseline Rate Normal : 110-160bpm

A Acceleration Should be present

Va Variability Normal : 5 – 25 bpm

D Deceleration Should be absent

Normal
O Overall assessment Non-reassuring
Pathological

DR – Define Risk
All high risk patients should be monitored by CTG whereas intermittent auscultation can
be used in the low risk group. Indications for CTG include:
A. Risk arising from maternal medical problems
i. Hypertension
ii. Diabetes
iii. Renal disease
iv. Collagen disease
v. Severe anaemia and haemoglobinopathies
vi. Cyanotic heart disease
vii. Hyperthyrodism

B. Risk arising from problem of the fetus

i. IUGR
ii. Post-term
iii. Preterm
iv. Oligohydramnios
v. Multiple pregnancy
vi. Breech
vii. Rhesus isoimmunisation

C. Risk arising from problem of labour

i. Induced labour
ii. Augmented labour
iii. Prolonged labour
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iv. Prolonged rupture of membranes

v. Previous LSCS
vi. Regional analgesia
vii. APH
viii. Intrauterine infection

D. Suspected fetal distress in labour

i. Meconium stained amniotic fluid
ii. Abnormal/ suspicious admission CTG
iii. Suspicious FHR on auscultation

C – Contraction (uterine activity monitoring)

Assessment of uterine activity includes the identification of contraction frequency,
duration and strength. Uterine activity can be assessed by manual palpation, or electronic
monitoring.

Manual palpation has been the traditional method of monitoring contractions. This
method can measure contraction frequency, duration and relative strength. Mild,
moderate and strong are the terms used to describe what is felt by the examiner’s hand
during palpation.

Palpation of the strength of contraction

Contraction strength Palpation sensation

Mild Tense fundus but easy to indent ( feels like touching finger to
tip of nose)
Moderate Firm fundus, difficult to indent with fingers ( feel like
touching finger to chin)
Strong Rigid, board like fundus, almost impossible to indent ( feel
like touching finger to forehead)

During labour, uterine activity is documented as how many contractions occur within 10
minutes and how long each contraction last and plotted on the partograph.
Electronic monitoring provides continuous data and a permanent record of uterine
activity. External uterine activity monitoring is achieved using the tocotransducer to
provide information on uterine contraction frequency, duration and an idea of relative
strength.

In a normal labour, uterine contractions occur about every 2 to 5 minutes, with a

duration of 30 to 60 seconds and increasing in strength from mild to moderate to strong
over the course of labour. Adequate or desired uterine contractions during labour is at
least 3 contractions within 10 minutes lasting about 40 seconds. Amniotomy, oxytocin
infusion or both are sometimes needed to augment the labour.

During intrapartum monitoring of uterine activity, it is important to look for

hyperstimulation of the uterus in addition to the frequency, duration and strength of the
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contraction. Hyperstimulation as evidenced by increased uterine activity can result in a

decrease in fetal oxygenation because of interference with the uteroplacental circulation.

Features of uterine hyperstimulation include:

a. Contraction lasting longer than 90 seconds
b. Relaxation between contractions less than 30 seconds
c. Contractions more frequent than every 2 minutes (> 5 in 10 minutes)
d. Peak pressure of contraction above 80 mm Hg.
e. Non-reassuring CTG

The most common cause of uterine hyperstimulation is the injudicious use of oxytocin.
When an oxytocin is discontinued, uterine relaxation usually occurs within 10 minutes,
with return of normal baseline FHR and variability. During an episode of
hyperstimulation, certain interventions will be required:
a. Continuous CTG monitoring
b. Discontinue or reduce oxytocin infusion (exercise caution in flushing the oxytocin
out of the line to ensure that a bolus is not delivered to the patient)
c. Increase rate of maintenance intravenous infusion
d. Change maternal position (left lateral preferred)
e. Consider use of tocolytic drug.

To ensure an optimal progress of labour and because uterine contractions are known to
decrease the rate of blood flow into the placenta, it is extremely important to attentively
monitor uterine activity in addition to FHR.

Interpretation of fetal heart rate (FHR) monitoring

When interpreting fetal heart rate, there are four main points to consider relating to the
fetal heart rate:
a. BR – Baseline heart rate
b. A – Acceleration
c. Va – Variability
d. D – Deceleration

BR – Baseline fetal heart rate (BHR) is the average level of fetal heart rate. It illustrates
the rate of fetal heart which is controlled mainly by the autonomic nervous system.
Baseline bradycardia is defined as being a persistently low baseline of below 110 bpm
whereas baseline tachycardia is defined as being a persistently high baseline of above 160
bpm.

a. Causes of tachycardia
1. Maternal tachycardia
2. Maternal pyrexia
3. Dehydration
4. Beta-agonist drugs
5. Fetal hypoxia
6. Fetal arrhythmia
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b. Causes of bradycardia
1. Maternal drugs – beta-blockers
2. Fetal hypoxia
3. Fetal arrhythmia

BHR at
around 120-
130 bpm

A – Accelerations are an increase in the fetal heart rate of 15 bpm or more lasting for at
least 15 seconds. Presence of accelerations indicate that the unborn baby is unlikely to
have acidosis. Nevertheless, absence of acceleration in an otherwise normal CTG does
not indicate fetal acidosis. It is no longer a feature to categorize CTG

Multiple
accelerations
seen on this CTG

Va – Variability (BV) can be measured by analyzing a one minute portion of a CTG, and
assessing the amplitude of change in the heart rate during that period.

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Variation in rate for every

heart beat (or beat-to-beat
variability)

a. Normal variability – a bandwith amplitude of 5 – 25 bpm

b. Reduced variability – a bandwith amplitude of < 5 bpm for more than 50 min
 Causes
1. Fetal hypoxia
2. Cerebral infection/anomaly
3. CNS depressants – opioids
4. Sleep – seldom under 5 bpm
c. Increased variability (Saltatory pattern) – a bandwith amplitude > 25 bpm
 May be seen in fetal hypoxia/acidosis due to fetal autonomic
instability/hyperactive sympathetic and parasympathetic system
d. Sinusoidal pattern
 Regular, smooth, undulating signal, resembling a sine wave, with an amplitude of
5-15 bpm, and a frequency of 3-5 cycles per minute, lasting more than 30
minutes.
 It is associated with severe fetal anaemia (eg: anti-D alloimmunization, fetal-
maternal haemorrhage, ruptured vasa praevia).

Regular, smooth,
undulating signal,
resembling a sine wave,
with an amplitude of 5-15
bpm, and a frequency of 3-
5 cycles per minute, lasting
more than 30 minutes.

D – Deceleration is defined as a reduction of the fetal heart rate of 15 bpm or more,

lasting for 15 seconds or more. There are 4 types of decelerations.

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a. Early decelerations occur when the onset of the deceleration is at the onset of the
contractions. The heart rate reaches its lowest point at the peak of the contraction
and has recovered to the baseline by the end of the contraction. It is usually
shallow and short-lasting. It usually occurs due to fetal head compression.

Multiple early decelerations seen

on this CTG
Note that there is also an
acceleration just before the 3rd
deceleration

Note that the lowest point of the

deceleration corresponds to the
peak of the contractions. This is
why it is considered EARLY
decelerations

b. Late decelerations occur when the lowest point of the deceleration occurs 30
seconds after the peak of the contraction. There will be gradual onset and/or
gradual return to baseline; with reduced variability within deceleration. It arises as
a result of a decrease in uterine blood flow and therefore decrease in oxygen
transfer to the fetus during uterine contraction.
c.

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d. Variable decelerations are inconsistent in shape and their relationship to uterine

contractions. Accelerations often precede and follow the decelerations. Variable
decelerations appear to occur as a result of transient compression of the umbilical
cord, between the fetus and surrounding maternal tissue or fetal parts, during a
uterine contraction.
o Typical variable deceleration (V-shape with shouldering) shows rapid
drop (onset to nadir in less than 30s) with good variability within
deceleration and rapid recovery to the baseline; seldom associated with
serious degree of fetal hypoxia/acidosis

V-shape with
shouldering

o Atypical variable decelerations (with concerning characteristics: lasting

more than 60 seconds (U-shaped), reduced baseline variability within the
deceleration, failure to return to baseline, biphasic (W) shape, no
shouldering) are significant features commonly associated with fetal
hypoxia/acidosis. It warrants an immediate attention and close monitoring.

W-shaped variable
deceleration

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U-shaped variable
deceleration

e. Prolonged deceleration is described as consisting of a drop in the fetal heart rate

of 30 bpm or more lasting for a period of at least 3 minutes. Prolonged
decelerations are caused by a decrease in oxygen transfer across the placenta to
the fetus.

Prolonged
decelerations.
The fetus needs to be
delivered
immediately

O – Overall interpretation of fetal heart rate (FHR) monitoring

There have always been two governance bodies to guide interpretation of CTG, namely
FIGO 2015 and NICE guidelines on intrapartum care. NICE guideline on CTG has been
practiced in SGH as it provides comprehensive and detailed description of the CTG as
well as the pathway of management of an abnormal CTG. However, it can be too
complicated that clinical management of CTG based on NICE’s Guideline is difficult
especially in district hospital.

On the other hand, FIGO guidelines on CTG interpretation is simple and easy to
understand. Nevertheless, FIGO guideline has its weakness. It does not address fetal
tachycardia (baseline heart rate of > 180 bpm). Neither does it address variable
deceleration. It is therefore important to be familiar with both guidelines.

For the purpose of training and clinical practice, it is crucial to have a standardized
guideline for CTG interpretation and classification. The following guideline is adapted
from the Revised CTG Guideline by FIGO and NICE’s guideline on CTG.

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Modified FIGO’s CTG guideline

Features Baseline rate Variability (bpm) Deceleration

(bpm)
Reassuring  110 -160  5 – 25  None or Early
Non-  100 – 109 or  < 5 for 30 to 50 min  Variable < 30 min or
reassuring  161 – 180 or  Late deceleration < 30
 > 25 for 15 – 25 min min
Abnormal  <100 or  < 5 for > 50 min or  Variable > 30 min or
 > 180  > 25 for > 25 min;  Late deceleration > 30
or min or
 Sinusoidal  single prolonged
deceleration lasting ≥ 3
min
* The presence of accelerations denotes a fetus that does not have hypoxia/acidosis, but
their absence during labour is of uncertain significance

Classification Normal Non-reassuring Pathological

Criteria  All 3  ONLY 1 non-reassuring  ≥ 2 non-reassuring
features are feature AND features
reassuring 2 reassuring features OR
 ≥1 abnormal feature
Interpretation  No fetal  Fetus with low  Fetus with high
hypoxia/ probability of hypoxia/ probability of
acidosis acidosis but the risk is hypoxia/ acidosis
increased

Management of CTG
During the interpretation of CTG, there are a few points of consideration:
1. Is the fetus hypoxic? If yes, does the fetus need urgent delivery?
2. What is/are the cause(s) of hypoxia? Are they reversible?

Management of CTG should take into consideration of the women’s parity, antenatal risk,
progress in labour, presence of meconium and most importantly the couple’s wish and
opinion.

Management of CTG based on the classifications

Classification Normal Non-reassuring Pathological

Criteria  All 3  ONLY 1 non-reassuring  ≥2 non-reassuring
features are feature AND features
reassuring 2 reassuring features OR
 ≥1 abnormal feature

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Interpretation  No fetal  Fetus with low  Fetus with high

hypoxia/ probability of hypoxia/ probability of
acidosis acidosis but the risk is hypoxia/ acidosis
increased
Clinical  No  Inform Medical Officer  Inform O&G
Management intervention for a full assessment. specialist urgently
 Correct reversible  Correct reversible
causes (e.g.: hypotesion/ causes (e.g.:
hyperstimulation). hypotension/
 Continuous CTG hyperstimulation)
monitoring and consider fetal
 Document a clear follow blood sampling. If
up plan of management. this is not possible,
 Inform O&G specialist expedite delivery.
if persistent non-  If acute events (e.g.:
reassuring or worsening cord prolapse,
CTG for further plan of placental abruptio,
management (e.g.: fetal uterine rupture), to
blood sampling). stabilize the patient
and arrange for
immediate delivery.
 If acute bradycardia
persists for 9
minutes, expedite the
birth

Actions To Correct Reversible Causes of Fetal Hypoxia

1. Hyperstimulation/tachysystole
a. To reduce or withold oxytocin
b. Tocolysis
c. Remove prostin
2. To relieve aortocaval compression with left lateral
3. There is no evidence to administer oxygen or intravenous fluid bolus (except in
cases of maternal hypotension)

Clinical risk management

 All non-reassuring or pathological CTG should be informed to Medical Officer

(MO) or specialist
 House officer (HO) should not decide on the management of non-reassuring or
pathological CTG without consulting Medical Officer or Specialist
 All CTG traces should contain patient’s name and identification number,
interpretation of the trace, the doctor’s signature, date and time
 CTG traces are legal documents. Keep it safely and document appropriately
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CARDIO PULMONARY RESUSCITATION IN THE

PREGNANT WOMAN
Objectives

 Able to respond appropriately to maternal collapse

 Understand and perform basic life support
 Understand the adaptations of CPR in the pregnant patient

Introduction
Cardiac arrest is fortunately a rare event in pregnancy. However, in the latest
MBRRACE-UK report for the triennium 2011-13, cardiac disease is again the leading
cause of maternal mortality overall. In terms of direct causes of death, the most common
cause is thromboembolism which also leads to cardiac arrest. It is therefore important
that the healthcare teams know the appropriate actions to take in such an event, to
promote positive outcomes for both the mother and the child.

Causes of cardiopulmonary collapse include

4 H’s 4 T’s
1. Hypovalaemia 1. Thromboembolism
2. Hypoxia 2. Toxicity
3. Hypothermia 3. Tension pneumothorax
4. Hypo/hyperkalaemia 4. Tamponade (cardiac)
(electrolytes disturbance)

Management – ‘DRS ABC’

D - Danger
The rescuer must ensure a safe environment

R - Response
Gently shake her shoulders and ask loudly “Are you all right?” If there is response, put
patient in recovery position. If no response, proceed to open and check airway.

S – Shout for help`

A - Airway
Place your hand on the patient’s forehead and gently tilt the head back (not if cervical
spine injury is suspected). At the same time lift the chin to open the airway by placing
your fingertips under patient’s chin. Jaw thrust may be required to open the airway in
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cases where cervical spine injury is suspected. Do this by placing fingers behind the
angle of the jaw and moving jaw anteriorly to displace tongue from the pharynx.

B - Breathing
Assess breathing for not more than ten seconds by looking at chest, neck and face for
absence of normal breathing or presence of abnormal breathing. Listening for breath
sounds and feeling for the movement of air is no longer part of BLS. If there’s no
breathing or abnormal breathing pattern is present, commence CPR. If there is normal
breathing pattern, to put patient in recovery position.

C - Circulation
With the patient tilted to the left with a wedge pillow (see below on “cardiac arrest in
pregnancy”), kneel by the side of patient and locate the lower half of the sternum:

 Using your index and middle fingers identify the lower rib margins
 Keeping your fingers together slide them up to the point where the ribs join the
sternum
 With your middle finger on this point place your index finger on the sternum
 Slide the heel of your other hand down the sternum until it reaches your index
finger; this should be the middle of the lower half of the sternum.

Place the heel of one hand there, with the other hand on top of the first.

Interlock the fingers of both hands and lift them to ensure that pressure is not applied
over the patient’s ribs. Do not apply any pressure over the top of the abdomen or tip of
the sternum.

Position your shoulders vertically above the patient’s chest and with your arms straight.
Press down on the sternum to depress it 5 - 6 cm, ensuring that the direction of
compression is perpendicular to the chest wall.

After each compression, release all the pressure on the chest without losing contact
between your hands and sternum.

Repeat at the rate of 100 – 120 compression per min.

After 30 compressions open the airway again using head tilt and chin lift and give 2
rescue breaths

Continue with chest compressions and rescue breaths in a ratio of 30:2

Basic life support (2 breaths to 30 compressions) should continue until advanced life
support arrives.

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Cardiac arrest in pregnancy

Precipitating events for cardiac arrest during pregnancy include pulmonary embolism,
trauma, peripartum haemorrhage with hypovolaemia, amniotic fluid embolism,
congenital and acquired heart disease, and complications of tocolytic therapy.

When the mother is supine, the gravid uterus (>20 weeks) compresses the major vessels
in the abdomen, mainly the Aorta and Inferior Vena Cava (See picture below)

This can cause hypotension and reduce cardiac output by as much as 30-40%. This can be
avoided by removing the compression and can be done by:

1. Tilting the patient 15-30 degrees to the left (using a wedge/board or the back of an
upturned chair or even your thigh)

2. Displacement of the uterus to the left (patient still in supine position)

In supine position while

CPR is being carried out,
an assistance displaces the
uterus to the left side.

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3. In cases of major trauma, the wedge should be placed under the spinal board. In
the absence of a spinal board, manual displacement should be used.

Provide defibrillation, intubation and pharmacologic agents in the usual manner.

Consider resuscitative hysterotomy if pulse has not restored in 4 to 5 minutes. Delivery of
the fetus is thought to obviate the effects of aortocaval compression and allow recovery
of venous return to the heart. Therefore delivery is indicated in any pregnancy above 20
weeks even if the fetus is not viable.

Recovery position
Kneel beside the victim and make sure that both her legs are straight

Place the arm nearest to you out at right angles to her body, elbow bent with the hand
palm-up.

Bring the far arm across the chest, and hold the back of the hand against the victim’s
cheek nearest to you.

With your other hand, grasp the far leg just above the knee and pull it up, keeping the
foot on the ground.

Keeping her hand pressed against cheek, pull on the far leg to roll the victim towards
your side.

Adjust the upper leg so that both hip and knee are bent at the right angles.

Tilt the head back to make sure that the airway remains open

Check breath regularly and be prepared to restart CPR immediately if she deteriorates or
stops breathing.

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Flowchart on management of maternal collapse

Maternal collapse

D – Out of danger
Personal protective equipment

R – Assess respond
“Are you alright?”

There’s NO response There’s response

S – Shout for Help

 Left lateral position
Senior personnel
 Assess breathing, vital
(Obstetrician, MO,
signs and FHR
anaesthetist, MA,
nurses)  Send for help
Activate Code  Find cause of maternal
Blue collapse
 Assess regularly
A – Open Airway
Head tilt, chin lift
Jaw trust
Clear airway (finger sweep)

B – Check Breathing
Assess breathing by looking
at the chest, neck and face
for 5 – 10 s

NO breathing Presence of
or abnormal normal
breathing breathing

C – Circulation (Commence CPR) Resuscitative hysterotomy

 Woman is tilted to the left  To be performed if there is no return of

 Start chest compression at the ratio of 30 spontaneous circulation after 4 minutes of
compression to 2 breaths correctly performed CPR
 Rate of 100/ min  Necessary for gestation beyond 20 weeks
 Keep arm straight; depress sternum for 5 – 6  To relieve aortacaval compression
cm  To be performed at the place where
 Continue CPR for 5 cycles of 30:2 and reassess resuscitation takes place
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ANTEPARTUM HAEMORRHAGE
Objectives

 Identify the major causes of antepartum haemorrhage.

 Know how to diagnose placenta praevia, placenta abruptio and vasa praevia.
 Understand the management of the major causes of antepartum haemorrhage.

Introduction
Antepartum haemorrhage is defined as any per vagina bleeding after 22 weeks of
pregnancy until the birth of the baby. The incidence is about 3 to 5 %. The causes can
vary from normal events like blood “show” from cervical dilatation to life threatening
situations like placenta abruptio. Most of the time, the cause is indeterminate. This
happens in about 45% of the cases. Other causes include placenta abruptio (30%) and
placenta praevia (20%). Local causes (5%) must be excluded which include vaginitis,
cervical polyp, ectropion and carcinoma.

History
Patients presenting with vaginal bleeding should be questioned about the characteristics
of the bleeding. What is the colour and consistency? Can she quantify the amount of
bleeding? Were there any precipitating factors like trauma or intercourse? Is the bleeding
associated with contractions or leaking liquor? Is there any fetal movements felt after the
onset of bleeding? Check the antenatal records to see if she has had an earlier scan for
low-lying placenta or placenta praevia.

If you determine that the patient is in labour, is the patient’s description of bloody
discharge consistent with a “show”? If so, evaluation of the patient can proceed in a
routine fashion. Otherwise, no speculum or vaginal examination should be carried
out until the location of the placenta is known.

General physical examination

Initial physical examination of any patients with antepartum haemorrhage should be
directed towards general resuscitative measures. Call for help and check for airway,
breathing and circulation as instructed in basic life support. Estimate the blood loss and
check for vital signs including heart rate, blood pressure and capillary refill. External
blood loss is unreliable in estimating the amount of blood loss in placenta abuptio as the
haemorrhage may be concealed or partially revealed.

Gain intravenous access and take 10 ml of blood for full blood count, group and
crossmatch 4 units of blood.

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Feel the abdomen for the presence or absence of contractions or hypertonic contractions
which may indicate placenta abruptio. Check for fetal heart rate and monitor the fetus for
viability. Do an ultrasound scan to locate the placenta. If there are no contraindications, a
speculum and vaginal examination may follow. A vaginal swab is taken if there is
leaking liquor or if infection is suspected.

Indeterminate Bleeding
In most cases, no identifiable cause of bleeding is found. If the mother and fetus is stable
and the bleeding has stabilized, such cases may be managed conservatively. Delivery is
warranted at 40 weeks in such cases because of possible placental insufficiency. In
patients presenting with per vaginal bleeding at term from any cause, delivery
should be considered. This includes patients who presented with a heavy blood show
where it is difficult to ascertain if the bleeding is a normal “show” or indeterminate
antepartum haemorrhage.

Placenta Praevia
This happens when the placenta is lying partly or wholly within the lower segment of the
uterine segment. If the placenta is within the lower segment of the uterus, there is minor
praevia. When the placenta covers the cervical os, major praevia is present. The incidence
at term is about 0.5%.

Risk factors for placenta praevia include previous lower segment caesarean section,
increased parity, increasing maternal age and multiple gestations. It is associated with
increased incidence of malpresentation, prematurity, intrauterine growth retardation,
placenta abruptio, postpartum haemorrhage and placenta accreta, the latter especially in
those with anterior placenta praevia and previous lower segment caesarean section.

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Placenta praevia usually presents with painless per vaginal bleeding. The bleeding is
revealed and the uterus is usually soft on palpation. Fetal heart beat is usually present. It
may be associated with abnormal lie or malpresentation.

This is usually diagnosed by transabdominal ultrasound. Sometimes, a transvaginal

ultrasound scan is needed for diagnosis, especially in minor placenta praevia situated
posteriorly. No speculum or vaginal examination should be carried out in placenta
praevia. Delivery is contemplated if there is maternal or fetal compromise. Consider
steroids if the fetus is preterm and tocolytics may be used in selected cases.

Patients with a history of antepartum haemorrhage due to placenta praevia may need to
be admitted until delivery. Blood should be available at all times for such patients as they
have a higher risk of bleeding again. Fortnightly serial ultrasound scans for placental site
and fetal growth should be carried out. Maintain the haemoglobin above 10g/ dl in such
patients so that there is adequate blood reserve in case of bleeding.

Patients with minor praevia may be allowed a trial of labour with continous
cardiotocograph monitoring in labour. If there is fetal compromise or significant
intrapartum bleeding, caesarean section should be carried out. Caesarean section is
indicated for all major praevia. The caesarean section should be carried out by an
experienced obstetrician, experienced anaesthetist and 4 units of blood must be available
in theatre at the time of caesarean section. It should be noted that posterior placenta
praevia is equally likely to be associated with postpartum haemorrhage as it can bleed
profusely from the placenta bed and lower segment of the uterus.

Placenta abruptio
Placenta abruptio is defined as the premature separation of the normally situated placenta.
The incidence is about 1 to 2%. The bleeding can be concealed with internal
haemorrhage, revealed or mixed with external haemorrhage.

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Maternal conditions associated with abruption include hypertensive disorders of

pregnancy, increasing parity, trauma, past history of abruptio, sudden decompression of
an overdistended uterus (e.g. twins, polyhydramnios), smoking, alcohol and substance
abuse.

It typically presents with painful per vaginal bleeding. The uterus is usually tender or
may be hypertonic with contractions. Fetal heart beat may not be detected. It may be
difficult to palpate the fetal parts because of the abruption and the distended uterus.

Management of patients with placenta abruptio depends on the viability of the fetus.
Partial abruption in a severely preterm fetus may be managed conservatively. If delivery
is warranted, the membranes may be ruptured to augment labour of the viable fetus and to
prevent amniotic fluid embolism. The fetus needs to be monitored continuously
throughout labour. If there are signs of persistent bleeding or fetal distress and delivery is
not imminent, caesarean section may be required. A paediatrician should be present for
the neonatal resuscitation.

If the fetus is not viable, assess maternal stability and signs of coagulopathy. In severe
abruptio resulting in fetal death, the average blood loss is about 2500ml. The risk of
coagulopathy is about 30%. The bleeding may not all be revealed and cause an
underestimation of blood loss. Adequate resuscitation is important to prevent
coagulopathy. Aim for vaginal delivery of the dead fetus unless haemorrhage is severe
and persistent.

Watch out for postpartum haemorrhage. A couvelaire uterus may be present. The uterus
looks “bruised” due to extravasation of blood into the myometrium. This may prevent
adequate uterine contraction and cause postpartum haemorrhage.

Vasa praevia
Vasa praevia is a rare cause of antepartum haemorrhage. Bleeding occurs at rupture of
membranes. Vessels may be felt in the presenting membranes. Immediate delivery is
warranted as the bleeding is of fetal origin. Perinatal mortality is high.

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POSTPARTUM HAEMORRHAGE (PPH)

Objectives

 To appreciate the contribution of PPH towards MMR.

 To understand definition of PPH and able to appreciate the severity of PPH.
 To understand and identify the main causes of PPH.
 To be competent in the management of PPH.

Introduction
Maternal death attributable to PPH has reduced over the years with 35% reduction of
maternal death from PPH from 2006 to 2014. Nevertheless, it is still an important and
one of the commonest cause of maternal death. It is responsible for 14.6% cases of
maternal death in 2011 according to CEMD 2009 – 2011.

In Sarawak, the incidence of maternal death from PPH has halved from 12 deaths in 2007
– 2011 to 5 deaths in 2012 – 2016. There has been no maternal death from PPH in
Sarawak General Hospital from 2007 – 2017.

Definition
1° PPH
Blood loss from the genital tract in excess of 500 ml in the first 24 hours of delivery.

2° PPH
Excessive bleeding from the genital tract after the first 24 hours postpartum until 6
weeks after delivery.

Severity

Severity Amount of blood loss (ml)

Minor 500 – 1000
Major > 1000
Massive > 1500
*RCOG defined severe PPH as blood loss of 2000 ml; however, with
the logistic of Sarawak, we would like to lower the threshold to
prevent potential delay in resuscitation.

Risk identification and Prevention

All pregnant women should have risk assessment for PPH during antenatal visits. Risk
identification allows a safe delivery plan to be outlined and documented in the woman’s
antenatal card. High risk women should be optimized before delivery. Safe delivery plan

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includes delivery in hospital with specialist and support from blood bank.

Risk factors associated with PPH

(Antenatal and Intrapartum risk)
Antenatal risks Intrapartum risks
1. Grandmultipara 1. Prolonged labour (first and second
2. Anemia in pregnancy stage)
(It was reported that anaemia is the 2. Precipitated labour
predominant risk factor in 25 – 28% 3. Prolonged third stage of labour or
of PPH in Malaysian tertiary retained placenta
hospital in 2011 – 1012) 4. Chorioamonionitis
3. Previous history of PPH 5. Episiotomy
4. Previous history of retained 6. Shoulder dystocia
placenta 7. Instrumental delivery
5. Previous history of caesarean 8. Women who receive MgSO4,
section nifedipine and salbutamol
6. Previous history of myomectomy 9. General anaesthesia
7. Multiple pregnancies
8. Macrosomia
9. Placenta praevia
10. Any bleeding disorder
11. Women on anticoagulant
12. Presence of uterine fibroid
13. Maternal obesity

Prevention of PPH
Antenatal
1. Optimization of haemoglobin level
by 36 weeks
2. Identification of high risk women:
Recommend woman with more than
1 risk factor should deliver in
hospital with specialist
3. Women who are high risk for PPH
from remote area may need to stay
near a hospital with specialist from
36 weeks
4. All pregnant women should have
placental localisation done by 28
weeks
5. Women with placenta praevia
should be managed accordingly
6. Women with previous caesarean
section and placenta praevia should
be referred to rule out abnormal
invasion of placenta ~ 53 ~ haematoma
Intrapartum and postpartum
1. Selective episiotomy
2. Modified active management of
3rd stage
3. Ensure that high risk women have
intravenous access with blood
cross match done
4. Ensure experienced trainees/
specialist performs or is present
during potentially difficult
caesarean section
5. Appropriate monitoring during
trial of vaginal delivery after
caesarean section.
6. Consider oxytocin infusion in
high risk women
7. Consider carbetocin in selected
women
8. Early recognition of perineal
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Management of PPH
General principles:
1. Recognition and assessment of severity
2. Communication and call for help
3. Resuscitation
4. Treatment – arresting the bleed
5. Monitoring and documentation

Communication, Resuscitation, Treatment, Monitoring should occur simultaneously

 Timing is vital in management of PPH
 Early involvement & intervention by consultant can be life saving

Recognition and Assessment

There should be a systemic assessment of a woman with PPH to establish:
1. The severity of the condition based on
a. Visual estimation of blood loss
b. Clinical signs and symptoms of hypovolaemic shock
c. Obstetric Shock Index
2. Cause of bleeding

Visual Estimation of blood loss

 Visual estimation of blood loss is inaccurate and is often underestimated!
 Pictogram of estimation of blood loss

Clinical signs and symptoms of hypovolaemic shock

Blood loss (ml) Pulse Blood Pressure Respiratory Mental Urine

(% of blood Rate Rate Status ouput
volume). (beats (breaths (ml/H)
Based on body per per minute)
weight of 50 kg min)
Up to 750 ml < 100 Normal 14 - 20 Normal > 30
(< 15%)
750 – 1500 ml > 100 Normal but may 20 - 30 Anxious 20 – 30
(15 – 30%) have narrow
pulse pressure
1500 – 2000 ml > 120 Reduced 30 - 40 Confused 5 – 15
(30 – 40%)
> 2000 ml > 140 Very low, can be > 35 Lethargic Nil
(> 40%) unrecordable
(Crit. Care. 2004; 8(5): 373 – 381)

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Obstetric Shock Index

 In obstetric haemorrhage, visual estimation of blood loss is always inaccurate and
blood loss is often underestimated.
 Physiological compensatory mechanism of pregnancy and postpartum may mask
decompensation until late in hypovolaemic shock.
 Abnormality in vital sign is late sign of hypovolaemic shock. This will lead to late
recognition of hypovolaemic shock, resulting in delay in resuscitation.
 Shock Index is defined as HR/SBP.
 For pregnant population, normal SI ranges from 0.7- 0.9;
 SI  1 predicts adverse clinical outcome.
 Therefore, it is suggested that SI can be used as early marker of decompensation
in haemorrhagic shock.

Obstetric Shock Index – HR/SBP (normal 0.7 – 0.9)

Causes of PPH
The causes of bleeding – 4 T’s
a. Tone (70%) – uterine atony
b. Trauma (20%)– genital tract trauma including uterine rupture
c. Tissue (10%) – retained placenta or product of conception
d. Thrombin (<1%) – preexisting or acquired coagulopathy (DIVC from placenta
abruption or severe preeclampsia)

Causes Assessment
Tone Rub the uterus to assess tone and size of uterus
Trauma Systemic examination of perineum with good lighting and in
lithotomy with position Sim’s speculum
 ‘Walk’ the cervix with non-traumatic clamps circumferrentially
o *Postpartum cervix can be raw with ragged edge which is
commonly mistaken as cervical tear
 Examination of vulva and vagina up to the fornices for tears
and haematoma
 Per rectal examination to assess for obstetrics anal sphincter
injury and button-hole tear
There should be high index of suspicion for uterine rupture in
high risk women – poor uterine contractility, bleeding from within
uterus, presence of free fluid from pelvic ultrasound, haematuria,
profound shock or sudden maternal collapse
Tissue Check for placenta and membrane completeness
Thrombin The cause should be evident from history of coagulopathy;
,l;otherwise, diagnosis of coagulopathy can be made from results of
fu,23ll blood count and coagulation screen.

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Reminder:
 If the woman is experiencing substantial amount of pain, or when the bleeding
is profuse, EXAMINATION UNDER ANAETHESIA SHOULD NOT BE
DELAYED.
 Assessment of blood loss and women’s condition should be a continuous
process during the resuscitation

Communication
Team work and effective communication is crucial! A resuscitative team should consist
of staffs with appropriate level of expertise as listed below according to the severity of
bleeding.

Essential elements of effective team dynamics:

a. Clear roles, responsibility and limitations of each member – team leader,
administer of drugs, runner, recorder
b. Each members should have competency and adequate knowledge in resuscitation
c. Closed-loop of communication
i. Call each other by names
ii. Make eye contact
iii. Respond to instruction to indicate the team members understand
instruction
iv. To inform team leader when task has been completed
d. Clear message
e. Mutual respect

Resuscitative team and supportive team during management of PPH

Minor PPH (500 – 1000 ml)
with no evidence of shock
1. Obstetric registrar or
senior obstetric trainees
2. Midwife in charged
3. House officer in charged
4. Anaesthetic trainees and
theatre staffs can be
alerted if theatre is
needed
*Obstetrician can be
acknowledged on the case
Major PPH (> 1000 ml) with on-going loss/
clinical evidence of shock
1. Obstetrician / Obstetric registrar or senior
obstetric trainees
2. Anaesthetist/ Anaesthetic trainees and
theatre staffs
3. Experienced midwives
4. House officer in charge
5. Blood bank personnel (transfusion trainees
and transfusionist, laboratory technicians)
6. Runner or porter
*RED ALERT or CODE RED should be
triggered in the event of massive PPH (blood
loss of 1500 ml or more) or earlier
*Consultant obstetrician should be present

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Resuscitation
Aim of resuscitation:
 Restoration of volume - Fluid resuscitation helps with restoration of blood
volume.
o Warmed cystalloid should be used first and should be infused according to
the ratio of blood loss: crystalloid – 1: 3.
o With further blood loss, plasma can be expanded with colloid at the ratio
of 2: 3 (ratio of blood loss: colloid)
 Restoration of oxygen carrying capacity.
o Blood transfusion restores oxygen carrying capacity and is usually
indicated when the blood loss is > 30%, depending on the woman’s
condition.

Minor PPH (500 – 100 ml)

1. Regularly communicate with the woman as indirect way of assessing her
conscious level
2. Set 1 large bore intravenous cannula of at least 18 G or 16 G
a. If bleeding continues, consider inserting another large bore IV cannula
3. Take blood for
a. Full blood count
b. Coagulation screen
c. Group and cross match 2 pints packed cell
4. Fluid resuscitation with cystalloid according to the ratio; blood transfusion is
rarely required

Major PPH (> 1000 ml)

1. Regularly assess Response of the woman; assess Airway; check her Breathing and
Circulation
a. When airway is compromised due to impaired conscious level, alert
anaesthetic colleague to secure airway
2. Place the woman flat and warm the woman
3. Supplementation of Oxygen up to the rate of 15 l/min via facemask
4. Set 2 large bore intravenous cannula – 14G or 16 G
5. Take blood for
a. Full blood count
b. Coagulation screen
c. Group and cross match 4 pints pack cell
d. Serum urea and electrolytes
e. Serum creatinine
6. Fluid resuscitation with cystalloid first and then colloid at the recommended ratio
while waiting for blood
7. Blood transfusion is usually necessary
a. In cases where urgent transfusion is needed, transfusion with safe ‘O’
blood can be done while waiting for cross matched blood
8. Massive Transfusion Protocol may be activated in massive PPH

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Treatment – Arresting the bleed

Treatment of PPH depends on the cause of bleeding. In certain cases, there may be more
than one cause of bleeding. Careful assessment to ascertain the cause is important.
Examination under anaesthesia should not be delayed in cases where assessment is
difficult.

Intravenous tranexamic acid infusion can be used in management of PPH (WOMAN

Trial)
1. Dose: 1gm (100mg/ml); infuse over 10 minutes (1 ml/min) dose can be repeated if
bleeding continues after 30 minutes or rebleeding occurs within 24 hours
2. It should be given early in PPH (within 3 hours)
3. It can be given in all causes of bleeding

Uterine Atony

1. Uterine massage
2. Empty urinary bladder with continuous bladder drainage
3. Oxytocics (1st line uterotonics) – oxytocin or syntometrine
 Oxytocin (Pitocin) – IM Pitocin bolus 10 units/IV Pitocin bolus 5 units slow bolus
over 1 – 2 minutes
o Dose may be repeated after 5 minutes – up to total dose of 10 units
o Start IV infusion of Oxytocin infusion 40 units in 1 pint normal saline for 4
hours (125 ml/H)
 Syntometrine – IM 1 ampule stat (5 units oxytocin and 0.5 mg ergometrine)
o Contraindicated in hypertension and cardiac disease
3. Carboprost (Haemabate)
 IM 250 g stat; can repeat up to maximum of 8 doses at 15 minutes interval
 HOWEVER, IF THE BLEEDING CONTINUES AFTER 3 DOSES,
CONSIDER SURGICAL METHODS TO STOP BLEEDING
4. Uterine tamponade with Bakri balloon (or Rusch balloon/modified uterine
tamponade with Foley’s catheter) – considered 1st line surgical intervention (refer to
appendices for further information on Bakri Balloon)
5. If uterine tamponade fails or bleeding continues, resort to other surgical intervention
 Uterine preservation
o B-lynch brace suture
o Uterine arteries ligation
o Internal iliac ligation
 Hysterectomy – resort to hysterectomy sooner as it is potentially life saving

Temporary measures while awaiting medications to work/awaiting theatre/transfer

 Bimanual uterine compression
 Aortic compression
 Anti-shock garment during transfer if available

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*VAGINAL PACKING IS CONTRAINDICATED IN PPH FROM UTERINE

ATONY AS IT WILL CAUSE HAEMATOMETRA WHICH RESULTS IN
FURTHER ATONY

Genital Tract Trauma

A. Vulval/vaginal tears:
1. Attempt immediate repair
2. For examination and repair under anaesthesia if repair is difficult.
3. If repair is not feasible or bleeding continues, control the bleeding temporarily
with vaginal packing while awaiting transfer (if it happens in district hospital)
or definitive management

B. Uterine rupture:
1. There should be high index of suspicion for uterine rupture in PPH
2. Examination under anaesthesia would be necessary
3. Exploratory laparotomy may be required and simple tears can be repaired
4. Resort to hysterectomy early
5. In district hospitals of Sarawak without O&G specialist, EUA can be
counter-productive. Consult specialist on call!

C. Uterine tear:
1. Can occur during difficult caesarean – deeply engaged presenting part,
deflexed fetal head; obstructed labour, fetal malposition or abnormal lie
2. Can result in broad ligament haematoma, bladder/ureteric injury
3. Requires experience surgeon to repair
4. Exteriorize uterus
5. Ensure adequate exposure of tear
a) Extension of incision if needed
b) Good assistant and retraction
c) Further deflection of bladder downward (to avoid bladder/ureteric
injury)
d) Use the suction catheter to clear the surgical field
6. Identify apex of tear and suture in 2 layers
a) If apex cannot be identified and extends beyond the cervix,
combined abdomino-perineal approach may be necessary
7. If extends laterally, open broad ligament (potentially dangerous engorged
venous plexus) to secure the apex
a. In this process, identification of ureter is crucial to prevent ureteric
injury
8. Insert drain upon closing of abdomen
9. In district hospitals, haemostasis with abdominal packing may be
considered as last resort if bleeding continues. Coagulopathy needs to be
corrected during transfer and before relaparotomy.

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Retained Placenta
Refer to the chapter of Retained Placenta

Monitoring and Documentation

Monitoring
Minor PPH (500 – 1000 ml)
1. Blood pressure, pulse rate and respiratory rate monitoring should be done every 5
minutes during episode for bleeding; once bleeding is controlled and vital signs
are stable, monitoring can be done at the interval of half hourly; Obstetric shock
index should be calculated as well
2. Parameters of monitoring, including obstetric shock index should be recorded in
Sarawak Obstetric Observation System (SOS)
3. The woman may be monitored in labour room/high dependency unit for another 2
– 4 hours for further bleeding
a. For women with Bakri Balloon in situ, monitoring in HDU shall continue
until removal of Bakri Balloon.
4. Continuous bladder drainage may be considered and strict input and output chart
should be in place
5. If the woman remains stable, she can be transferred to level 1 care (normal ward
in acute bed) after careful assessment by O&G trainee

Major PPH (> 1000 ml)

1. The woman should be nursed in level 3 (ICU) or level 2 (HDU) care
2. Continuously pulse rate, oxygen saturation, blood pressure (possibly by invasive
blood pressure monitoring) and respiratory rate monitoring; obstetric shock index
monitoring
3. Monitor temperature
4. Record parameters into SOS chart and prompt action taken if abnormal scores
from SOS are obtained.
5. Continuous bladder drainage and strict fluid balance charting. Overzealous fluid
resuscitation may predispose to acute pulmonary oedema
6. Monitor blood parameters – FBC, coagulation screen, renal and liver profile;
monitor blood gases
7. Optimize haemoglobin level, correct coagulopathy and correct acidosis if
necessary (co-management with Intensivist/anaesthetic team

Documentation
Systematic documentation after each event of PPH is of paramount importance,
especially if the event has resulted in maternal death. Proforma can be designed to record
the important information related to the event of PPH. PPH management checklist is
available in Sarawak General Hospital (refer Appendices)

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Secondary PPH
Abnormal or excessive bleeding from genital tract after 24 hours to 6 weeks of delivery

Causes
1. Infection (most common)
2. Retained product of conception
3. Unrecognized lower genital tract trauma
4. Bleeding disorder
5. Persistent trophoblastic disease (uncommon)
6. Others – chronic sub-involution of uterus (uncommon), uterine AV malformation
(rare)

Management
General principles of management are essentially similar to management of primary PPH

1. Recognition and assessment of the severity. Establish the cause of secondary PPH
a. Assessment of uterine involution (sub-involution may suggest retained
product of conception)
b. Speculum examination and high vaginal swab taken for C&S
c. Pelvic ultrasound to look for retained product of conception
d. Blood taken for necessary investigation – blood culture, full blood count,
coagulation screen, serum electrolyte, group and screen/cross match
(depending on the severity)
2. Communication – transfer the woman to hospital with specialist
3. Resuscitation
4. Treatment depending on the cause
a. Intravenous broad spectrum antibiotic should be initiated
b. Uterotonics to be given if indicated
c. Consider surgical evacuation of uterus where retained tissue is suspected –
the procedure can be done after 12 hours of antibiotic with the last dose of
antibiotic given within an hour of procedure or immediately in the event of
massive bleeding.
d. Procedure should be performed by experienced surgeon and under
ultrasound guidance as the risk of uterine perforation is significantly
higher
e. In massive bleeding with empty uterus, uterine tamponade with balloon
catheter may be considered with antibiotic cover
f. When conservative measures fail and bleeding is massive, surgical
measure such as hysterectomy may be undertaken
5. Monitoring should be as in primary PPH.

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Postpartum Care for PPH

Immediate Postpartum

Monitoring
Close monitoring should be done as mentioned in Section 6.11.3.5. A
multidisciplinary team approach shall be advocated and involvement of consultant in
immediate postpartum care will be invaluable.
Thromboprophylaxis
1. Massive PPH is an added risk for thromboembolism.
2. Intermittent pneumatic calf compressor should be used while awaiting
coagulopathy to be corrected.
3. Medical thromboprophylaxis should be started as soon as coagulopathy is
corrected and there is no active bleeding

Debriefing
1. PPH, especially massive PPH is considered major event which is rather traumatic
to the woman and her family
2. There should be an effective and on-going communication between healthcare
team, patient and her partner/immediate family member.
3. There should be documented debriefing by managing specialist/consultant;
debriefing should include sequence of events that occur and the progress;
4. Counselling should include future implication – timing, place and mode of
delivery for next pregnancy; risk of Sheehan’s syndrome in the extreme case of
massive PPH
5. Debriefing of healthcare staffs involved in the event may be necessary

Follow up and long term plan

1. Follow up plans and home visits should be arranged; there should be
communication between managing team and primary health care worker to ensure
adequate postnatal care
2. There should be detailed plan for next pregnancy with regards to timing, place
and mode of delivery documented in discharge summary
3. Biohazard screen can be arranged for women who has massive transfusion
4. Psychological impact from PPH can be significant; therefore this issue should be
addressed during postnatal care
5. Contraception should be addressed during follow up

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Summary

PPH Management

Call for help Obstetricians, Anaesthetist, Transfusionist

Senior midwives/nurses & Houseman

Initial action ABC including vital signs (BP, PR)

2 large-bore cannulas (14- to 16- gauge)
Take blood – FBC, PT/APTT, GXM 4 units blood
Set up IV Drip

Resuscitation Crystalloid/Colloid/Blood (depending on EBL)

Tone Massage uterus

Tone - Oxytocics Either oxytocin, syntometrine @ ergometrine

• Oxytocin (Pitocin) – IM 10 units stat/IV 5 units stat (dose
can be repeated x 2 – a total dose of 10 units)
• Syntometrine – IM 1 ampule stat
• Ergometrine – IM 0.5mg stat
• Carboprost (Haemabate) – IM 250 ug stat (15 min apart)
o Maximum 8 doses (resort to other methods if not
working after 3 doses)
Also start IV oxytocin infusion (40units in 1 pint) run @
125ml/hour – to maintain contraction

Tissue Check placenta/membranes

Trauma Check vagina/cervix

Thrombosis Blood investigations results

Tone Bimanual compression – last resort, while awaiting for OT or

transferring patient

EUA Examination under anaesthesia

HDU/ICU Close monitoring post-delivery

Location depending on the condition of the patient

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GUIDE TO TRANSFUSION OF BLOOD AND BLOOD

COMPONENTS
Objectives

 To know the variety of blood products

 To know the right time and the indications to start blood or blood product
transfusion
 To know the complications of massive transfusion

Variety of blood components

Blood Volume Contents Effects Compatibility

products (ml/unit)
Packed red 280 +/- 50 RBC, WBC, Increase HCT ABO and RH
cells plasma by 3%, increase
Hb by 1gm/dL
Platelets 50 +/- 10 PLT, RBC, Increase PLT ABO and RH
WBC, plasma between 5 – 10
x 109/L
Fresh frozen 200 - 250 fibrinogen, Increase ABO, no need
plasma antithrombin fibrinogen by RH
III, factor V 10 mg/dL compatibility
and VIII
Cryoprecipitate 40 +/- 10 Fibrinogen, Increase ABO, no need
factor III, XIII, fibrinogen by RH
Von 10 mg/dL compatibility
Willebrand
factor

Fresh frozen plasma contains at least 70 IU/ ml of Factor VIII in 75% of the volume.
Fresh frozen plasma can be centrifuged to produce cryoprecipitate which has a high
concentration of Factor VIII, vonWillebrand Factor, Factor XIII, fibronectin and
fibrinogen. Cyrosupernatant contains mainly albumin and is depleted of Factor VIII and
fibrinogen. This is not truly fresh frozen plasma per se but is commonly included as such
in some hospitals.

Once thawed, fresh frozen plasma and cryoprecipitate need to be used immediately as the
coagulation factors denature easily. It may be stored at 40 C and transfused within 24
hours but it will lose its coagulation factors with time.

Platelets must be kept at 220 – 240 C and stored in an agitator to prevent clumping.

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Group and rhesus specific blood should be transfused at all times where possible. In an
emergency, Group O Rhesus negative blood (low haemolysin titre) may be used.

Group specific blood components, other than red blood cells should be given at all
times. In an emergency, Group AB (does not contain anti A or B Ig) Rhesus negative
blood products may be given. No anti-D prophylaxis is required if a RhD-negative
woman receives RhD-positive FFP or cryoprecipitate.

All red cell and platelet components should be CMV-seronegative in pregnancy

Indication of blood transfusion

Whole blood
Whole blood can be processed to yield:
1. Packed cells
2. Platelet concentrate
3. Fresh frozen plasma. This can be centrifuged to form
a) cryoprecipitate
b) cryosupernatant

There is no data to suggest that the use of whole blood is associated with better outcome
in acute blood loss.

It is used in exchange transfusion and for acute blood loss.

Red cells transfusion

The indications for red cells transfusion should be based on clinical judgement. The
indications are as below:
1. In acute blood loss, indication for transfusion is based on multiple factors; it
should be of blood loss based on clinical factors
 Based on haemoglobin concentration
o Hb > 10 g/dl – not indicated
o Hb < 7 g/dl – indicated
o Hb 7 – 10 g/dl – less clear; depends on situation and patient
 Based on risk of further blood loss
 Based on the estimation of blood loss

Blood loss (ml) Type of fluid resuscitation

(% of blood volume). Based
on body weight of 50 kg
Up to 750 ml -
(< 15%)
750 – 1500 ml Crystalloid to replace fluid loss
(15 – 30%)
1500 – 2000 ml Rapid volume replacement with crystalloid or colloids;
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(30 – 40%) Red cells transfusion is likely to be necessary

> 2000 ml Blood transfusion is required immediately
(> 40%) Volume replacement with crystalloid/ colloid is
necessary while waiting for blood.
Consider safe O blood/ uncrossmatched blood
Active Massive transfusion protocol
*This is only applicable for women with optimal baseline haemoglobin level and
without cardiovascular co-morbidities. In woman with suboptimal haemoglobin or
cardiovascular disease, the threshold of red cells transfusion should generally be
lower.

2. Other indication includes

 Perioperative haemoglobin optimisation
 Chronic anaemia
 Anaemia in critical care

Platelet
 In DIVC or at platelet transfusion trigger of 75,000/l

Fresh frozen plasma and cryoprecipitate

 In DIVC (evidenced clinically or from coagulation screen) with evidence of
bleeding
 There is no evidence for prophylactic FFP transfusion to prevent DIVC or to
reduce transfusion
 In massive transfusion with on- going blood loss and haemostatic test result is not
available
o FFP should be administered for every 4 units of red cells transfusion; aim to
maintain APTT < 1.5 at the dose of 12 – 15 mls/kg
o Cryoprecipitate should be administered early in major obstetric haemorrhage
at the dose of 1 – 2 units/kg to keep fibrinogen > 1.5 g/l

Therapeutic Aims of transfusion

Factor Aims
Haemoglobin >8g/dL
Platelet >50K
PT/PTT ratio <1.5 times
Fibrinogen > 2.0 g/dL

Massive Transfusion
Massive blood transfusion may be defined by one of the following:
1. Replacement of total blood volume in less than 24 hours or,
2. Loss of 50% blood volume in less than or equal to 3 hours or,
3. 150ml/ min blood loss.
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These definitions are of limited clinical significance as they are retrospective.

Massive Transfusion Protocol (MTP)

Massive Transfusion Protocol (MTP) a trigger system in place to activate the blood
bank and other staffs (haematology lab) to obtain necessary blood products in time to
avoid lethal triad of dilution coagulopathy, metabolic acidosis and hypothermia in
major haemorrhage.

The protocol should include:

1. A designated number to call to activate MTP

2. Activation of MTP should trigger a cascade of events that include:
a. Taking blood for baseline investigations: Full blood count,
coagulation screen including fibrinogen, group and crossmatch
b. Emergency release of safe ‘O’ blood if crossmatched blood is not
available
c. Transfusion of Red cells:FFP:Platelet in at least 1:1:2 ratio (may
consider the ratio of 1:1:1)
d. An effective mechanism to trace lab results
3. Transfusion can be continued at ratio of at least 2:1:1 if bleeding continues
and lab results are not available; may consider giving cryoprecipitate
4. If lab results are normal but bleeding continues, repeat massive transfusion
till bleeding stop
5. When results are available, transfusion of blood product is tailored to
correction of the abnormalities of result
6. The cycle continues till bleeding stops and MTP is deactivated

Communication is crucial in major haemorrhage with massive blood transfusion as

mentioned in PPH Chapter. There should be a Team Leader, who is usually the Senior
Obstetrician or Anaesthetist, to co-ordinate further management and for decision
making. Team members play a vital role in communicating with blood bank and
laboratory staffs; nurses/doctors for taking blood for investigations and a porter to send
blood investigations or collecting blood products from blood bank.

Complications of Massive Blood Transfusion

Adverse effects
Immune mediated Acute/delayed Haemolytic Transfusion Reaction
Transfusion Related Acute Lung Injury
Anaphylaxis/Anaphylactoid Reaction
Febrile Non Haemolytic Transfusion Reaction
Allergic Reaction
Transfusion Associated Graft Versus Host Disease

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Non-immune mediated
Metabolic disturbances
(TaGVHD) – rare
Post-Transfusion Purpura - rare
Alloimminization
Bacterial contamination
Transfusion Transmitted Infection
Transfusion Associated Circulatory Overload (TACO)
Hyperkalaemia
Hypocalcaemia
Acid base disturbance
Hypothermia

Disseminated Intravascular Coagulopathy (DIVC)

Precipitating factors:
 Massive / rapid blood loss (APH / PPH)
 Abruptio placenta
 Septicaemia / chorioamnionitis
 Amniotic fluid embolism
 Pre-eclampsia
 Intrauterine death
 Septic miscarriage
 Molar pregnancy

Clinical signs
 Petechiae spots & ecchymosis
 Bleeding from venepuncture site
 Absence of clot formation in operative field

Biochemical manifestations
 Low platelet
 Prolonged PIT
 Prolonged PT
 Reduced/absent serum fibrinogen
 Prolonged BT/CT

Management:
Principle of management:
1. Identify coagulopathy and the primary cause
a. Call for help - initiate RED ALERT upon recognition of DIVC
b. Do not wait for biochemical evidence if DIVC is clinically evident
2. Treatment of underlying cause/triggering factors – many a time this involves
delivery or evacuation of product of conception
3. Correct acidosis with sodium bicarbonate and hypoxia with oxygen
4. Maintain circulatory volume - use crystalloids / colloids / plasma.

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5. Correct coagulopathy
a. Liaise with blood bank personnel in the management of cases
b. Personnel to mobilize and coordinate to ensure availability of
blood and blood products.
c. Use whole blood while awaiting blood products especially in massive
hemorrhagic cases.
d. Transfuse the necessary blood products
6. Evaluate response to therapy by monitoring:
a. Coagulation profile - PT/ APTT, fibrinogen, platelet count, FDP.
b. If no laboratory test available, assess clinically by looking for:
i. Excessive bleeding from wound;
ii. Oozing from venepuncture sites and raw area;
iii. Evidence of new purpura / bleeding.
7. Repeat treatment with components if haemostasis is not secured
8. Organize for HDU/ ICU monitoring of patient - after stabilization

The “standard DIVC regime for all” is no longer practiced. There are various
regimes of DIVC depending on the women’s weight, severity of her condition, on-
going blood loss, blood investigation and local resource. The various regimes are as
stated below:

Regime Components
‘Standard regime’ (60 kg 6 units (1 – 2 units/ 10 kg) cryoprecipitate
patient) 4 units (12 – 15 ml/kg) FFP
2 - 4 units of platelet

Alternative regime Red cells:plasma:platelet ratio = 1:1:1; or

(especially in massive Red cells:plasma:platelet ratio = 2:1:1 (especially in
bleeding/refractory DIVC) district hospital where there are limited blood
products

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RETAINED PLACENTA
Objectives

 Recognize risk factors for retained placenta.

 Understand the technique for removing a retained placenta.

Introduction
According to NICE guidelines on Intrapartum Care:
 3rd stage of labour is the time from the birth of the baby to the expulsion of the
placenta and membranes.
 The management of the 3rd stage can be either active or physiological.
o Active managemeent of the 3rd stage involves routine use of uterotonic
drugs, deferred clamping and cutting of the cord, and controlled cord
traction after signs of separation of the placenta.
o Physiological management of the third stage involves NO routine use of
uterotonic drugs, NO clamping of the cord until pulsation has stopped,
delivery of the placenta by maternal effort.
 In general, active management is used as it reduces the risk of PPH and the need
for blood transfusion.

Retained placenta or a prolonged 3rd stage is defined as failure to deliver the placenta
within 30 minutes of the birth with active management or within 60 minutes of the birth
with physiological management.

The incidence varies from 1 in 200 to 1 in 100 deliveries. Risk factors include previous
retained placenta, multiparity, induced and preterm labour, small placenta, placenta
praevia, chorioamnionitis and leoimyoma. It is also associated with scarring of the uterus
with caesarean section, sharp or suction curettage. Postpartum hemorrhage is commonly
associated with retained placenta.

Manual removal of placent (MRP)

1. Once retained placenta is diagnosed, blood should be taken for full blood count
and cross matching.
2. Manual removal of placenta (MRP) should be booked within 30 minutes of
the diagnosis of retained placenta
3. MRP under sedation or bedside MRP is not recommended. It should be done
under spinal or general anaesthesia in the OT.
4. IV oxytocin infusion (40 units) should be started if the patient is bleeding. NICE
no longer recommends intraumbilical cord agents or routine intravenous
oxytocics for removal of retained placenta.
5. If the woman is bleeding actively, communicate with the theatre so that the
procedure can be done as urgent as possible.
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6. Under sterile conditions, the operator’s hand is introduced into the cavity of the
uterus and a plane of cleavage identified. By moving the fingers from side to
side (see-saw pattern), this plane of cleavage is extended until the whole
placenta is free form the wall of the uterus. The placenta is then removed.
7. The cavity must then be re-explored to ensure it is empty.
8. Once empty, IV infusion of oxytocin 40 unit in 500 ml of crystalloid should be
commenced at 125 ml/H
9. If there is no identifiable plane between the placenta and uterus, abnormal invasion
of placenta should be suspected. The procedure should be abandoned if the patient
is not bleeding. Inform the specialist. Forcefully removing it can result in uterine
inversion or further bleeding.

Below is a summary of the management of retained placenta:

Retained placenta is diagnosed when there is failure to deliver the

placenta within 30 minutes of the birth with active management or
within 60 minutes of the birth with physiological management.
Inform colleagues Medical officer
Senior MA/Nurse

Initial action IV access

Take blood – FBC, GSH

If PPH Manage as in PPH

Immediate MRP (either in labour room or OT)
IV oxytocin infusion (40 units) should be started if the patient is
bleeding

If retained >30 min MRP in OT under anaesthesia

In OT IV antibiotics stat dose (according to local protocol)

Stop IV oxytocin infusion if started earlier
Lithotomy position

MRP technique Follow umbilical cord into uterus

Identify edge of placenta
Stabilize uterus bimanually
Separate placenta by using “see-saw” method
Separate whole placenta before removal

After placenta Check placenta & membrane for completeness

If not complete, re-explore the uterus (i.e. Digital curettage)
delivered Check for other injuries

Post-MRP Maintain IV oxytocin 40 units @ 125 ml/H

Pad chart, watch out for further PV bleeding

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MRP technique
Follow the umbilical cord into
the uterus. This step ensures that
your hand is guided into the
uterus.

Identify the edge of the placenta.

Ensure that the uterus is stabilize
at the fundus with the other hand.

Separate the placenta using the

see-saw @ sliding method.
Ensure the placenta is fully
separated before removing it.
Check the placenta/membrane
completeness
Check for other lower genital
tract injuries

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Morbid placental adherence (placenta accreta)

If a plane of cleavage cannot be identified during manual removal of placenta, placenta
accreta should be suspected. Further attempts to manually remove the placenta should be
abandoned. Persisting in trying to find a plane where none exists has been shown to cause
major haemorrhage.

A major risk factor for placenta accreta is uterine scarring. The incidence increases with
previous caesarean section. Prior manual removal or uterine curettage may also cause
scarring and increases the risk of placenta accreta. Raised beta-hCG, elevated second
trimester serum alphafetoprotein and age > 35 years are also risk factors.

Maternal mortality is lower if an aggressive operative approach i.e. hysterectomy is

instituted and thus, this must be considered as the safest approach where haemorrhage is
severe. Sometimes, the placenta is left in-situ and patients are managed expectantly.
Methotrexate have also been used in patients where the placenta is left in place.

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UTERINE INVERSION

Objective

 To recognize and understand the management of uterine inversion.

Introduction
Uterine inversion is rare but a life threatening complication of third stage of labour,
which places women at risk for significant haemorrhage and shock. Uterine inversion
may be preventable.

The reported incidence of uterine inversion varies, but the average estimate is one in
2,000 deliveries.

The fundus of the uterus is the

part where the inversion starts

Further inversion, with the

fundus going through the cervix
into the vagina

Complete inversion.
Note that the lower part of the
uterus is the last part to invert.

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Prevention
Mismanagement of the third stage of labour, such as excessive traction on the umbilical
cord and excessive fundal pressure, may combine with placental implantation in the
dome of the uterus, uterine atony, or congenital weakness of the uterus to cause uterine
inversion.

Mismanagement of the third stage should be avoided and cord traction should not be
applied until the signs of placental separation are apparent.

Prevention
• Wait for signs of separation
– Gush of blood
– Lengthening of cord
– Globular contracting uterus
• Ensure proper CCT is applied during
3rd stage
• Apply counter traction on the
abdomen (pushing up the uterus) to
stabilize the uterus

Recognition
Early recognition of uterine inversion is vital to enable prompt treatment. Symptoms and
signs include:
 Severe lower abdominal pain in the third stage
 Haemorrhage, present in 94% of cases
 Shock that is out of proportion to the blood loss due to increased vagal tone
 Placenta, may or may not be in-situ. About half the time the placenta will remain
attached
 Uterine fundus not palpable per abdomen (in milder degrees there may be a
dimple in the fundal area)
 Pelvic examination showed a mass in the vagina (in milder degrees) or outside the
introitus
.

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May feel a dimple at the
top of the fundus

Incomplete inversion

Inverted uterus might not be obvious

as it is still at the level of the cervix
Might find a mass in the vagina
(which is the inverted uterine fundus)

Uterine fundus won’t be

felt per abdomen

Complete inversion

Placenta still attached.

DO NOT detach the placenta UNTIL
the uterine inversion is replaced

Management
1. Call for help (experienced obstetrician/ anaesthetist/ senior nursing staff).
2. Arrange replacement of uterus concurrently to anti-shock measures, as
resuscitation may not be successful until the inversion is corrected.
(When inversion is recognized, attempt to replace the uterus by hand immediately)
3. Insert two wide-bore cannulas.
4. Collect blood for FBC, coagulation studies and group and crossmatch (4-6units).
5. Start fluid replacement immediately (colloids and crystalloids).
6. Continuously monitor BP/ pulse/ respiratory rate/ urine output/ O2 saturation.
7. Arrange appropriate analgesia/ antibiotic prophylaxis
8. Transfer to theatre.
9. Attempt to reposition the uterus; the earlier the restoration, the more likely the
success (if the placenta is still attached, it should be left alone until after
repositioning. Removal may precipitate severe haemorrhage)

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Replacement techniques
 Manual replacement (the Johnson maneuver)
 Hydrostatic replacement (the O’Sullivan’s technique)
 Surgical replacement

Manual replacement (the Johnson maneuver)

Preferably under general anaesthesia. The uterus may require relaxation for manual
replacement to succeed. Press first on that part of the corpus which was inverted last.

Replace the part of the uterus which invert

last.
The other hand is used to support the
fundus of the uterus and helps in pushing
the uterus in.

Note that the fundus is not yet replaced.

The lower part of the uterus is gradually
replaced.

Once the uterus is in the abdomen, the

supporting hand is used to support the
uterus on the abdomen.

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The fundus, which is the part of the uterus

to invert first, is the last part that is
replaced.
Keep your hand in the uterus and give
oxytocics.
Once you feel the uterus contracting, do
MRP
Keep the hand in the uterus until the uterus
is firmly contracting on your hand.
Subsequently, gradually remove your hand
to prevent re-inversion

Hydrostatic repositioning (O’Sullivan’s technique)

Uterine rupture must be excluded first.
The inverted uterus is held within the vagina by the operator and the introitus sealed
with the 2 hands of an assistant. Infuse warm saline, 2 litres or more, into the vagina
(via a large rubber tube held 1-2 meters above the patient)
Another technique involves attaching a large rubber tube to a silicone ventouse cup
inserted in the vagina, which tends to produce a better seal.

Insert one hand into introitus with the tube

connected to the drip.
Seal the opening with the help of an
assistant to prevent water leakage

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Surgery (Laparatomy and Haultain’s procedure or Huntingdon’s operation)

Surgery is only used if all other attempts fail.

 Huntingdon’s procedure
o Allis forceps are placed within the dimple of the inverted uterus and gentle
upward traction is exerted on the clamps with a further placement of
forceps on the advancing fundus.
 Haultain’s technique
o Incise the cervical ring posteriorly with a longitudinal incision. This
facilitates uterine replacement by Huntingdon’s method. This is aided by
an assistant from below.
When the uterus is reverted, give oxytocin, ergotmetrine or Prostaglandin F2
(Haemabate) to keep the uterus contracted and prevent the inversion from recurring.
The attendant’s hand should remain in the uterine cavity until a firm contraction
occurs.

Role of tocolytic drugs in uterine inversion

 Tocolytics are used to relax the cervical ring to facilitate replacement
 Agents include:
o Salbutamol 75-150 mcg IV bolus
o Ritodrine 150 mcg IV bolus
o Volatile agent administered by general anaesthesia (e.g. halothane)

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SHOULDER DYSTOCIA

Objectives

 Able to recognize shoulder dystocia

 Discuss the limited predictive value of prenatal and intrapartum risk factors
associated with shoulder dystocia.
 Understand the techniques to manage shoulder dystocia and how to use them
 Recite the mnemonic HELPERR.

Introduction
Shoulder dystocia remains one of the most dreaded obstetric complications and one that
is often unanticipated. It is one of the primary causes of perinatal mortality and
morbidity, maternal morbidity and a costly source of litigation. Certain risk factors have
been identified, but their predictive value is relatively low. One must be prepared for the
possibility of shoulder dystocia in all deliveries, and have a prepared plan of
management.

Definition
Shoulder dystocia is the impaction of the anterior shoulder against the symphysis pubis
after the head has been delivered, and occurs when the breadth of the shoulder is greater
than the biparietal diameter of the head.

Incidence
The overall incidence 0.58-0.7%. 48% occurs in BW <4kg. Over 50 % of shoulder
dystocia occurs in the normal birth weight infant and are unanticipated.

Prediction
Risk factors have low positive predictive value for shoulder dystocia. However,
identifying those patients at risk for a potential shoulder dystocia during labour can result
in necessary preparation, including preparing labour and delivery staff, notifying
appropriate additional personnel and ensuring the availability of equipment.
Risk factors for Shoulder Dystocia
Antepartum risks Intrapartum risks
1. Macrosomia 1. Prolonged first stage
2. Maternal diabetes 2. Secondary arrest
3. Previous history of shoulder 3. Prolonged second stage
dystocia 4. Oxytocin augmentation
4. Maternal obesity 5. Assisted vaginal delivery
5. Induction of labour ~ 80 ~
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Diagnosis
Diagnosis can be made when routine axial traction fails to deliver shoulder and extra
obstetric maneuvers are needed to release the shoulder.

There should be high index of suspicion for shoulder dystocia when there’s ‘head
bobbing’ during second stage or ‘turtle neck’ after delivery of the head.

Complications

Complications of Shoulder Dystocia

Maternal complications
1. Postpartum haemorrhage
– 11%
a. Uterine atony
b. Genital tract trauma
c. Uterine rupture
2. 3rd and 4th degree tear –
3.8%
3. Litigation
Fetal complications
1. Neonatal death
2. Hypoxic ischaemic encephalopathy
 Due to compression of carotic arteries
 pH of fetus drops 0.04 per minute;
therefore delivery should occur by 5
minutes
3. Brachial plexus injury
 Most significant complication
 Incidence of 2.3 – 16%
 Most cases resolve without permanent
disability
 10% - permanent neurological disability
 Erb’s palsy – the most common injury
 Involves the fifth and sixth cervical
roots
4. Humeral or clavicular fracture

Management
The first rule of treatment is anticipation and preparation. Shoulder dystocia usually
becomes obvious after the head emerges, retracts up against the perineum and standard
delivery maneuvers fail to deliver the fetus.

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Mnemonic - HELPERR

Mnemonic Term Action

H Help Call for help

staff/nurse)
(paediatrician, obstetrician, senior

E Episiotomy Perform adequate/generous episiotomy

L Legs McRobert’s manoeuvre

P Pressure Suprapubic pressure

E Enter Wood screw manoeuvre

R Remove Removal of the posterior arm

R Roll Roll the patient over to hands and knees

R Repeat Repeat the above procedures (from ‘L’)

H – Help
This means asking for extra personnel including an experienced nurse or midwife,
obstetrician and paediatrician. The necessary equipment should also be ready.

E – Episiotomy
If an episiotomy was not performed, you should do a generous one. If it was done,
you may have to extend the episiotomy to provide adequate space.

Remember: Episiotomy is done not to overcome the shoulder dystocia but rather,
to provide space for you to carry out the maneuvers to overcome the shoulder
dystocia.

L – Legs
The simplicity of the McRoberts maneuver and its proven effectiveness makes it
an ideal first step in management. The procedure involves flexing the maternal
thighs up onto the maternal abdomen, which simulates the advantages of a
squatting position, increasing the inlet diameter. The legs need to be removed
from the stirrups to allow for this maneuver.

The McRoberts maneuver also straightens the lumbosacral lordosis, removing the
sacral promontory as an obstruction. This procedure simultaneously flexes the

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fetal spine, and often pushes the posterior shoulder over the sacral promontory,
allowing it to fall into the hollow of the sacrum.

Finally, the direction of maternal force in this position is perpendicular to the

plane of the inlet. When successful, normal traction should deliver the fetus after
the patient is in this position. This maneuver is sufficient to deliver about 90% of
shoulder dystocia. Delivery should be attempted in this position for approximately
30 to 60 seconds. However, the clinician should be planning and preparing for the
next maneuver if this is unsuccessful. The patient can remain in this position
through the next two maneuvers.

McRobert’s maneuver
 Hyperflex the hips
 Abduct the hips
 Flex the knees

Preferably done with 2

assistant, each at both sides of
the patient

P- Suprapubic Pressure
External pressure should be attempted for approximately 30 to 60 seconds. This
procedure involves suprapubic pressure by the assistant with a “CPR” hand over
the anterior shoulder forcing it to rotate to an oblique position. The direction of
pushing should be in the direction of where the baby is facing. Initially, the
pressure can be continuous, but if delivery is not accomplished, a rocking motion
is recommended to dislodge the shoulder from behind the pubic symphysis. If this
procedure fails, the next procedure should be immediately planned.

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Pressure is applied at the

suprapubic region, and not on
the symphysis pubis/pubic
bone.

Note that the mother is still in

McRobert’s position

Direction of push is downwards

and towards the direction where
the baby is facing.
Objective: To disimpact the
shoulder and push it to an
oblique position

Important: It is important to know the first 2 steps as the McRobert’s position and
suprapubic pressure is sufficient to deliver about 80-90% of shoulder dystocia.

E – Enter: Woods’ screw maneuver (WSM)

Enter the vagina for WSM.
The Woods’ screw maneuver is accomplished by using one hand to apply
pressure to the posterior aspect of the anterior shoulder while the other hand apply
pressure to the anterior aspect of the posterior shoulder.

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Anterior shoulder
 Apply pressure on the
posterior aspect

Posterior shoulder
 Apply pressure on the
anterior aspect

Initially, attempt is made to displace the shoulder into an oblique diameter,

thereby reducing the impacted anterior shoulder. If this fails, the procedure is
completed by continuing the rotation a full 180 degrees, making the anterior
shoulder become the posterior shoulder, allowing the delivery to be accomplished.

Oblique Displace into an oblique position.

position If fail to deliver, rotate a full 180o

Rotate 180 o

The maneuver can be very difficult, particularly when the anterior shoulder is
partially wedged underneath the symphysis. You might not have space to put in 2
hands into the vagina. In this case, use only one hand to try and turn the
shoulders.

At times, it is necessary to push the posterior shoulder or sometimes the anterior

shoulder backup into the pelvis slightly in order to accomplish the maneuver.

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R – Remove the posterior arm

The clinician’s hand is inserted into the vaginal in front of the fetus. Identify the
posterior arm and elbow. Ensure the elbow is flexed across the front of the body.
Grasp the hand and deliver the arm by sweeping it across the chest and face. The
anterior shoulder can be delivered in the usual manner.

Flex the forearm at the elbow if

the forearm is extended.

Deliver the arm by sweeping it

across the chest and face.

This procedure is quite difficult and is sometimes associated with humeral

fracture, maternal lacerations and extension of episiotomy to a third degree tear.

R – Roll the patient to her hands and knees

This involves putting the patient on her hands and knees on all-fours (Gaskin
maneuver). In this position, the posterior shoulder (with reference to the woman)
is delivered first and then the anterior shoulder.

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This position is called “on

all-fours”, knee-chest
position or hands-and-knee
position.

It may be easier to remove the posterior arm when the mother is in this position,
as the baby is pulled by gravity, creating more space for you to put your hand in
and deliver the posterior arm.

This procedure may not be feasible for obese mothers or when the delivery bed is
small.

R – Repeat the above procedures from McRoberts maneuver

If the above maneuvers are unsuccessful, all maneuvers may be tried again. The
order in which each maneuver is attempted may be revised.

There are several “last resort” maneuvers when the above maneuvers fail. These include:
 Symphysiotomy – cutting the symphysis pubis to allow delivery of the anterior
shoulder
 Clavicular fracture (@cleidotomy) – allows further adduction of the fetal
shoulder, reducing the diameter of the shoulders, thus allowing delivery
 Zavanelli maneuver – push the baby’s head back into the uterus and proceed
with emergency caesarean

The Zavanelli maneuver (cephalic replacement and caesarean section) has been described
but success rates vary with limited safety data. This involves flexion of the fetal head
after it is in a direct occipital anterior position followed by cephalic replacement with
continuous pressure on the fetal head until caesarean section can be accomplished.
Tocolysis may be valuable in this situation. Symphysiotomy and intentional fracture of
the clavicle have also been advocated.

Post-event Management
After any delivery complicated by shoulder dystocia, we should always be alert to the
possibility of postpartum haemorrhage and extended perineal tears. Babies should be
examined by the pediatric team to rule out any brachial plexus injuries and a full
explanation of intrapartum events should be given to the mother/couple.

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Documentation of the timing of the events and the sequence of manoeuvers performed as
well as the personnel in attendance is also extremely important for risk management and
audit purposes.

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ASSISTED VAGINAL BREECH DELIVERY

Objectives

 Discuss the risks and benefits of planned caesarean section version vaginal breech
delivery for a breech baby at term
 Understand the techniques of vaginal breech delivery
 Understand and able to manage the complications of vaginal breech delivery,
including after-coming head entrapment

Introduction

The incidence of breech presentation is about 20% at 28 weeks. However, as most

fetuses will turn spontaneously nearing term, the incidence of breech presentation at term
is only about 3-4%.
As a result of the Term Breech Trial (TBT) which was published in 2000, planned
caesarean section for breech babies was thought to significantly reduce perinatal
mortality and this resulted in an almost worldwide increase in caesarean section rates.
However, the subsequent and much larger PREMODA study (2006) has demonstrated
that with the implementation of strict intrapartum management criteria and trained
personnel, vaginal breech delivery is actually safe. This has also been validated in other
smaller trials.

Management

Overall, breech presentation at term is associated with uterine and congenital

abnormalities and hence, breech presentation itself is associated with worse outcomes
regardless of the actual mode of delivery. Nonetheless, all women with a breech at term
should be offered external cephalic version (ECV) at 37 weeks if there are no
contraindications. This is because a vertex vaginal delivery is still considered safer than
a breech vaginal delivery.
In women whom a successful ECV has been performed, the pregnancy and delivery
should be managed as for a woman whose baby has always been cephalic.
For women who refuse ECV / failed ECV, there should be a detailed discussion
regarding mode of delivery. In carefully selected women who are planning to give birth
in a center which is familiar with vaginal breech deliveries, the option of vaginal delivery
may be discussed.

Vaginal breech delivery Elective caesarean section

Pros Pros
 No difference in neonatal unit  Avoids risk of pregnancy after 39
admissions / Long term morbidity weeks
 Faster recovery in successful  Avoids risk of labour
vaginal delivery
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Cons Cons
 Increased risk of low Apgar scores  Increase in immediate
 Increased risk of neonatal trauma complications for the mother
 Increased short-term neonatal  Impact of a previous caesarean
morbidity section in future pregnancies
 Need for emergency caesarean   perinatal mortality in VBAC
section (40%)   risk of placenta
praevia/abnormally invasive
placenta
In summary, the risk of perinatal mortality is
~ 0.5/1000 with caesarean section after 39 weeks
~ 2.0/1000 with planned vaginal breech delivery
~ 1.0/1000 with planned cephalic delivery

 Increased risk of perinatal death by 1/1000 in vaginal breech delivery compared to

cephalic delivery.

In the setting of a district hospital, women with a breech baby in labour should be advised
for caesarean section in district or sent to the nearest specialist hospital. However, it is
not unusual for women with known / undiagnosed breech pregnancies to present to the
district hospitals / clinics with advanced labour where the birth is imminent. In these
cases, the attending staff may have no choice but to conduct a vaginal breech delivery.
This is why all maternity staff and doctors should be familiar with the steps of a vaginal
breech delivery.

Vaginal breech delivery

 Prepare to conduct a vaginal breech delivery only if birth is imminent for a baby
in a frank breech / flexed breech position. (Baby buttocks on perineum)
 Ensure continuous fetal heart rate monitoring.
 Delivery should be conducted by the most experienced personnel available.
 Another MO / Paediatric MO should standby for neonatal resuscitation.
 Deliver in lithotomy position with mother’s buttocks at the end of the bed.
 Drain bladder before commencing active second stage.
 Follow the basic principle of “Hands OFF technique”.

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General principles

• “Hands-off” technique!
• Allow breech to descend
with contractions and
maternal effort.
• Active pushing should
only be encouraged when
the breech has descended
to the pelvic floor and is
visible.

• Do not pull the baby out!!!

• Traction will lead to
extension of the fetal head
as well as fetal arms and
further complicate the
delivery!

• Wait until the anus is

visible over the fourchette
before carrying out an
episiotomy.
• Protect the fetal bottom
from being cut with your
left hand.
• The breech will usually be
delivered with the sacrum
to the right or left of the
mother. Do not allow the
sacrum to turn posteriorly!
• Insert two fingers at the hip
to guide the sacrum
anteriorly as the mother
pushes the baby out.

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Delivery of the fetal legs

 Keep the sacrum anterior while awaiting delivery of the fetal legs.
 Extended legs can be “walked” out by the ‘Pinard maneuver’ – apply gentle
pressure on the popliteal fossa to encourage flexion of the knee and lateral
rotation of the thigh. Grasp the fetal foot and deliver the leg.
 Deliver the anterior leg first, then rotate the baby slightly to deliver the opposite
leg.
 Conventionally, a loop of cord is brought down if the cord is tight. If the cord is
loose, do not manipulate the cord as this may lead to vasospasm!
 Very rarely, a short cord will prevent descent of the body. This will require cord
division and quick delivery.

• Once the baby is partially out,

you can wrap the baby in a
warm clean towel. This is to
keep the baby warm as well as
prevent the baby from slipping
out of your hands!
• Hold the baby only at the pelvic
bony regions and legs
• Thumbs on sacrum
• Index fingers on ASIS
• Last 3 fingers on thigh
• DO NOT hold the abdomen
(soft tissue) or chest

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Delivery of the fetal arms

 Allow baby to descend with maternal effort.

 Once the scapula is visible, you can expect the arms to deliver spontaneously.
 If the arm does not deliver spontaneously, sweep two fingers over the shoulder
until you reach the elbow and bend the arm to bring the hand out in front of the
baby.
 Rotate the baby slightly and deliver the opposite arm in a similar manner.
 Remember to always keep the baby’s back facing upwards.

Nuchal arm / Extended arm

 Lovset maneuver is done by holding
the baby at the hips and applying
downward traction while rotating the
baby 180◦ to bring the posterior
shoulder anteriorly under the pubic
arch.
 The anterior arm can then be delivered
by flexing the elbow and sweeping the
hand over the baby’s face.
 Turn the baby back 180◦ (always keep
the back facing upwards) and deliver
the other arm in a similar manner.
 Subsequently, laterally flex the baby
and turn the baby back 180o. Make sure
the baby’s back is facing upwards
during turning. Deliver the arms that
comes to rest in front of the baby.

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Baby’s body cannot be turned

 If the baby cannot be turned, try to
deliver the posterior shoulder first.
 Lift the baby upwards and laterally,
then deliver the posterior arm.
 Lay the baby back down and the
anterior shoulder should now deliver as
usual.

Delivery of the fetal head

Mauriceau-Smellie-Veit method
• Allow baby to hang down with support until the posterior hair line can be seen.
• Place your Index and middle finger on baby’s maxillary prominence while
supporting the baby on your forearm.
• Do not to insert finger into baby’s mouth! (Risk of jaw fracture & TM joint
dislocation)
• Place your other hand over the baby’s shoulders with your middle finger over the
occiput.
• Both hands are used to flex the baby’s head and deliver in the direction of the
birth canal.

You can ask an assistant to apply

suprapubic pressure to help flex
the baby’s head.

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 Burns-Marshall technique is no longer advised due to risk of over-extension of

the fetal neck.
 Piper forceps can be used to help flex and deliver the aftercoming head. An
assistant needs to help lift the baby while the forceps is placed below the baby.
 In preterm breech deliveries, head entrapment may occur due to inadequate
cervical dilatation. In this case, Dührssen’s incision may be required – cervical
incision at 2-, 6-, and 10-o’clock to help release the fetal head.
 As a general guide, baby’s head should be delivered within 5 minutes from the
delivery of the buttocks, or within 3 minutes from the deliver y of the umbilicus.
 If baby is vigorous, allow delayed cord clamping as usual.

Post-delivery of the fetus

 Proceed with active management of 3rd stage.

 Watch out for PPH.
 Check for cervical tears / perineal trauma.
 Counsel mother regarding intrapartum events and any complications that may
have occurred.
 Document all procedures clearly in the casenotes.

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TWIN PREGNANCY

Objectives

 Assess the suitability for vaginal twin delivery

 Safe management of vaginal twin delivery

Introduction
The background incidence of twin pregnancies is 1 in 80 pregnancies. Dizygous twining
rates vary enormously depending on age, parity, racial background and assisted
conception techniques. Monozygous twinning rates are relatively constant with an
incidence of 4 per 1000 births. Overall, perinatal mortality and morbidity is higher in
multiple pregnancies than in singletons. Premature delivery and the complications of
prematurity are the main contributors to adverse outcomes. Other factors contributing to
the risk are intrauterine growth restriction, congenital anomalies, malpresentation, cord
prolapse and placenta abruptio.

The use of routine ultrasound assessment has facilitated the diagnosis of multiple
pregnancies. Women who have attended for antenatal care should have had the
chorionicity of the pregnancy determined (during first trimester – before 14 weeks) and
undergone serial growth scans from 16 weeks onwards until delivery.

The Twin Birth Study looked at the outcome of planned vaginal birth versus planned
caesarean section for twin pregnancies, and concluded that there was no significant
benefit of caesarean section for twins. Therefore it is reasonable to aim for vaginal
delivery if the first twin is cephalic. MCDA twins are usually planned for delivery after
completion of antenatal corticosteroid at 36 weeks, whereas DCDA twins can be
delivered around 37 weeks. Of course, parental opinion and consent is important, and it
is not unreasonable to perform elective caesarean sections for twin pregnancies if
requested by the couple. In women with a previous caesarean section scar and a current
twin pregnancy, a repeat caesarean section is normally advised regardless of the
presentation of the twins.

Presentation
Twin I vertex
Assess the suitability for vaginal delivery. As it is difficult to predict the eventual
presentation of the second twin at the time of delivery, the situation should be favourable
for breech delivery.

If the second twin is non-vertex, vaginal delivery is still considered safe as long as twin I
is vertex.

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Twin I Non vertex

The incidence of locked twins is low, at 1:1000 twin births. However, due to the high
morbidity of twin I in locked twins, caesarean section is advised if twin I is non-vertex.

Inter- twin delivery internal

Recent studies support the view that no specific time interval needs to be set, provided
that there is continuous electronic FHR monitoring of twin II and that it is reassuring.

The intrapratum management of vaginal twin delivery

Admission to labour ward

 Intravenous line
 Blood tests—FBC, group & save
 Continuous CTG monitoring
 If at any stage either twin cannot be monitored then caesarean section may be the
only safe option

Ultrasound assessment
Do ultrasound scan to determine:
 Presentation of each fetus
 Liquor volume assessment
 Placental site
 Viability of each fetus
 Estimation of fetal weight if not recently performed

Inform
 Paediatrician
 Anaesthetist
 Obstetrician

Management of first stage

 Manage as for singleton pregnancy in terms of induction and augmentation of
labour, and expected labour progress.
 Ensure continuous CTG monitoring for both twins
o Ideally, both twins should be traced by one machine, to produce both fetal
heart tracings on the same piece of paper to allow for easy comparison.
o Always compare both tracings to ensure that two different heart rates are
being traced and same twin is not being monitored twice!
o If there is difficulty in obtaining the trace for both twins, consider
inserting an internal probe for the first twin and maintaining the abdominal
probe for the second twin.
o An ultrasound scan can also be used to help locate the fetal heart positions
of both twins.

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Management of second stage

 Preparation needed:
o 10IU of oxytocin in 500 ml of Hartmann’s solution, if not already
receiving oxytocin infusion.
o Ultrasound machine
o At least 2 doctors for the delivery + 2 doctors for neonatal resuscitation
o 3 cord clamps
o Foley’s catheter – KIV to drain bladder especially if anticipating breech
delivery of second twin
o Extra syringes for cord blood
o 1 vial of syntometrine / 5 units of oxytocin
 Deliver twin I as if singleton.
o Clamp the cord using 2 cord clamps and cut in between the clamps.
Postpone taking any samples for cord blood until the second twin is
delivered.
 Perform abdominal palpation to determine lie for twin II. Second assistant should
help to stabilize the baby in a longitudinal lie.
 Confirm lie, presentation and fetal heart with ultrasound scan.
 Monitor CTG continuously.
 If transverse lie, perform ECV or IPV (internal podalic version).
 If lie is longitudinal, encourage pushing with each contraction. Once presenting
part has descended into the pelvis, perform amniotomy with contraction.
 If no contractions within 5-10 minutes commence oxytocin infusion.
 Once twin II has been delivered, clamp and cut the cord as usual. You can
differentiate both cords as the first twin will have a plastic cord clamp whereas
twin II will have a metal clamp. Proceed to withdraw any cord blood which is
necessary. Cord pH should be taken if the baby was born not vigorous.
 Casearean section may be necessary for twin II. Therefore, facilities for caesarean
section must be immediately available.

Active management of third stage

 Give Syntometrine 1 ampoule (or oxytocin 5 iu if Syntometrine is
contraindicated) after the delivery of the second twin.
 Deliver the placenta using controlled cord traction and check the placenta to
confirm chorionicity and ensure placenta and membranes are complete.
 Consider oxytocin infusion (40 IU oxytocin in 500 ml of Hartmann’s solution), as
there is a risk of uterine atony and PPH following delivery of multiple
pregnancies.

Internal podalic version (IPV)

The technique used for internal podalic version has been described.

A fetal foot is identified by recognizing a heel through intact membranes. The foot is
grasped and pulled gently and continuously lowered into the birth canal. The membranes
are ruptured as late as possible followed by breech vaginal delivery.
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This procedure is easiest when the transverse lie is with the back superior or posterior. If
the back is inferior or if the limbs are not immediately palpable, ultrasound may help the
operator to identify where they may be found. This will minimize the risk of bringing
down a fetal hand.

How to do Internal Podalic Version

1) A hand is introduced into the uterus and the

anterior foot is grasped by the heel. (Pulling on
the posterior limb tends to turn the baby’s back
to the back of the uterus. If possible both feet
should be grasped.)

2) Downward traction is applied on the leg and

the outside hand presses the head upwards.

3) Gentle traction is applied on the delivered leg

until the breech is fixed, then the other leg is
extracted and the delivery completed by the
obstetrician.

The arms will invariably extend as a result of

traction and Lovset’s manoeuvre can be applied,
followed by delivery of the head as usual.

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CORD PROLAPSE
Objectives

 To be able to diagnose cord prolapse

 To learn how to manage cord prolapse
 Proper documentation

Definition
When part of the cord falls beyond the presenting part in the presence of ruptured
membrane.
(Cord presentation is the presence of cord beyond the presenting part in the presence of
intact membrane)

Occult cord prolapse – descent of cord alongside the cervix

Overt cord prolapse – descent of cord beyond the presenting part

Incidence
Overall incidence of cord prolapse is 1 – 6/1000
 0.5% in cephalic
 0.5% in frank (extended) breech
 5% in complete (flexed) breech
 15% in footling breech

Predisposing factors
1. Fetal
 Prematurity
 Multiple gestations
 Fetal anomaly – anecephaly
 Malpresentaton – breech, transverse, oblique

2. Maternal factors
 Multiparity
 Contracted pelvis
 Pelvic tumour/mass

3. Liquor
 Polyhydramnios

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4. Placenta
 Placenta praevia
 Long cord
 Ruptured of membrane

5. Iatrogenic procedures
 Artificial rupture of membrance
 External cephalic version
 Internal podalic version
 Placement of intrauterine pressure transducer/forceps/scalp electrode/fetal scalp
sampling

Diagnosis
Cord prolapse can diagnosed by appearance of loop of cord outside of vagina or pulsation
of cord felt on vaginal examination.

Cord prolapse should be suspected when there is fetal heart rate abnormalities especially
if it occurs after membrane rupture.

Cord prolapse should be excluded at every vaginal examination in labour and after
rupture of membrane.

How can cord prolapse be prevented?

Patients with non-cephalic presentations and preterm prelabour rupture of membranes
should be recommended for in-patient care.

Artificial membrane rupture should be avoided whenever possible if the presenting part is
mobile and/or high. If artificial membrane rupture is necessary, it should be performed
with stabilizing ARM and in a centre with facilities for immediate caesarean section.

Rupture of membrane should be avoided if cord is felt below the presenting part.

Management
Management depends on the viability of the fetus.

In cases of intrauterine death, we should aim for vaginal delivery.

If the fetus is alive, cord prolapse is an obstetric emergency. Delivery should be

expedited and caesarean section is the mode of delivery of choice if vaginal delivery is
not imminent.

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A category 1 caesarean section should be performed to achieve birth within 30 minutes or

less if cord prolapse is associated with abnormal fetal heart rate.

Category 2 caesarean section birth can be considered in cases where the fetal heart rate
tracing is normal. Ensure close continuous CTG monitoring while awaiting for caesarean
section as any changes would warrant a category 1 section.

Paediatricians or practitioners competent in the neonatal resuscitation should be present

at all births that follow cord prolapse.

Ways to reduce/relieve cord compression by the presenting part

1. Minimise handling of the umbilical cord outside the vagina to prevent spasm.
Both manipulation of the cord and exposure to air may cause vasospasm. But
there is no proven benefit of wrapping the cord with warm soaked gauze.

2. Place hand in the vagina with cord cradled on palm and fingers elevating the
presenting part.

3. Elevate the buttock using a pillow/tredenlenberg position/knee-chest

position/Sims position – lying left lateral with hip elevated with a pillow. Upon
transfer of a patient with cord prolapse in an ambulance, the knee-chest position is
potentially unsafe and Sims position should be advocated.

4. Filling up the bladder with 500 ml – 800 ml normal saline.

5. Tocolysis can be considered while preparing for caesarean section.

Clinical Governance
Patient and partner should be adequately counselled and debriefed as the event is a
stressful event to them.

Proper documentation should be done as cord prolapse can be a potential medico-legal

case.

Training of staffs and drills should be carried out regularly to improve competency of
staffs in managing cord prolapse.

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INSTRUMENTAL DELIVERY

Objectives

 Discuss the indications for forceps and vacuum extraction

 Know the prerequisites for the use of forceps and vacuum extraction
 Understand outlet, low, mid and high forceps
 Know how to do forceps and vacuum extraction

Forceps delivery
Introduction
The obstetric forceps is a very useful instrument provided that the accoucher is familiar
with the technique of its use and its possible dangers. An accurate abdominal and vaginal
examination and assessment is extremely important before decision to perform forceps
delivery is made. Always remember that the caesarean section is a safer option to a
difficult instrumental delivery which is likely to produce a traumatized baby.

Indications
a. Maternal indications
i. Delay in the second stage, commonly due to poor maternal effort.
ii. Maternal distress
iii. Conditions where a short second stage is desirable e.g. eclampsia, heart
disease.
b. Fetal indications
i. Fetal distress in the second stage
ii. Delivery of after coming head in breech delivery

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Classification of forceps delivery

Type of procedure Criteria

Scalp is visible at the introitus without separating labia
Fetal skull has reached pelvic floor
Fetal head is at or on perineum
Outlet forceps Sagittal suture is in anteroposterior diameter or right or left
occiput anterior or posterior position
Rotation does not exceed 45o

Leading point of fetal skull is at station  +2cm and not on the

pelvic floor
Low forceps a. Rotation  45o (left or right occiput anterior, or left or
right occiput posterior to occiput posterior)
b. Rotation > 45o

Midforceps Station above +2cm but head engaged

Head not engaged. This forceps is INAPPROPRIATE in
High forceps modern obstetrics and has been replaced by the use of
caesarean section.

Responsibility
Decision for forceps deliveries should be made by registrars, specialists or consultants on
duty. Medical officer or house officer may be permitted to perform forceps deliveries
with the supervision of a registrar or specialist on duty. Only outlet and low forcep
deliveries are permitted. The decision for midcavity forceps or trial of forceps should
only be made by the specialist.

Prerequisites for instrumental deliveries

The use of forceps is permissible only when all of the following conditions prevail,
regardless of the urgent need for delivery.

Forceps Vacuum

F Fully dilated os - Same -

O Occiput anterior or posterior Any position

R Ruptured membranes - Same -

Cephalopelvic disproportion excluded - Same -

Cephalic 0/5 @ Station ≥ +1
C Consent (verbal)
Contraction

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Empty bladder - Same -

E Episiotomy
Pain relief – pudendal, epidural, GA - Same -
P Paediatrician on standby
Skill/experience of operator - Same -
S Sterile procedure

Procedure
1. The fetal head should be checked before the procedure.
2. Aseptic technique is used. Gowning is necessary.
3. The operator should be seated in front of the patient, and all maneuvers should be
made carefully and slowly.
4. The forceps blades are assembled and checked to make sure that they form a pair.
5. The patient is placed in lithotomy position. Putting a wedge under one buttock helps
to prevent aortocaval compression.
6. Clean and drape.
7. Vaginal examination is done again to confirm the following
a. Dilatation of the os
b. Position and station of the presenting part
c. Adequacy of the pelvis
8. If the position cannot be determined due to caput, the ears may be used as landmarks
for locating the occiput. If the ears cannot be reached, the presenting part is still high.
Thus, the decision for forceps delivery should be reevaluated.
9. Pudendal block and local infiltration of the episiotomy site with lignocaine 1% or 2%
if the patient is not on epidural. (Maximum dose for lignocaine 1 % is 20 ml. Do not
inject into vessels as cardiac arrhythmias can result.)
10. Episiotomy is done at crowning or when the head distends the perineum.
11. The left blade (to be placed at the left side of the mother’s pelvis) is selected and the
handle is held between the finger and thumb of the accoucher’s left hand. The blade
rests in the cupped right hand and the handle is approximately parallel with the
mother’s right inguinal ligament. Two fingers of the right hand are inserted in the
vagina to guide the blade into position alongside the fetal head, as the handle is
swept round in an arc. Only minimal force is necessary. If application is not possible
or too much force is needed, something is wrong and the situation should be
reassessed.

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This is a good way to hold the forceps.

The left hand and fingers guide the
blade into the vagina while the right
hand holds the handle like a pencil grip
(with the fingers and thumb and not
clenched in the hand).

Introduce the left blade first. Remember

“Left blade, left hand, left side of the
pelvis”.
The handle is held vertically.

Placement of the blade is completed by

swinging the handle down to the
horizontal plane.

12. The right blade is applied in a similar manner

Subsequently, introduce the right blade

(right blade, right hand, right side of the
pelvis) similarly to that of the left blade.
Note the left blade is already at the
horizontal position.

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13. With minor adjustment, the blades should lock easily.

Both blades introduced. The 2 handles

are brought together and locked. If
application is correct, the handles lock
precisely, without using any force.

14. Before applying traction, you may have to correct the position of the head to an OA
position if it is slightly rotated.

Before traction, rotate the head to an

OA position

15. Traction is applied by the fingers placed between the shanks of the forceps. The
direction of traction should be in axis of the birth canal. Traction is applied
synchronously with uterine contractions. The mother is encouraged to bear down.
The operator is advised to adopt a seated position to avoid use of excessive force. It
is wise to unlock the forceps slightly in between contractions.
16. In low forceps, the initial traction is almost in the horizontal direction, with a slight
downward component.

Direction of traction depending on the

position of the head.

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17. Lack of descent suggests disproportion.

18. Crowning and delivery are achieved in a controlled manner by swinging the handles
of the forceps upwards, so that the head/neck extends.

As the head extends, the handles

are raised until they pass the
vertical. Little force is needed.
One hand suffices; the other hand
may support the perineum

19. Remove the blades once the head is delivered.

20. After delivery of the placenta, the vagina and cervix should be examined for
lacerations. These are repaired.
21. The baby is checked for trauma and attended by the paediatric colleague.

Ventouse/Vacuum delivery
Introduction
The obstetric vacuum extractor, sometimes called the ventouse, is an instrument which,
like the forceps, may be used to assist a woman during delivery. Compare to the
obstetrics forceps, ventouse has the advantage of encouraging flexion and autorotation of
the fetal head during delivery.

Indications are the same as forceps delivery with the exception that the ventouse can be
used in the late first stage in selected cases. Ventouse is also suitable for OT position
because it can bring autorotation. The prerequisites for forceps deliveries are also
applicable for ventouse delivery.

Procedure
1. The patient is placed in the lithotomy position.
2. The bladder is catheterized.
3. A cup of the appropriate size is chosen. Generally, this should be done with one of
the larger cups. (5 or 6 cm diameter)
4. Perineal infiltration with local anaesthetic agent.
5. The cup is applied to the fetal head, placing it along the sagittal suture and as far
back as possible (touching the posterior fontanelle). If the cup is off the midline,
traction will cause asynclitism which result in a larger head diameter. If the cup is
placed further forward than the flexion point (see picture), the head will be deflexed
when traction is applied.

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Correct and incorrect vacuum cup application

The vacuum cup should be placed at the flexion point, which is the point on the fetal
head 2cm in front of the posterior fontanelle, in the midline. When traction is applied
at the flexion point, the baby’s head will flexed fully, allowing the smallest diameter
of the head to present at the introitus.

6. Before the vacuum is created, vaginal examination must be done to ascertain that no
soft tissues are caught between the cup and the head.
7. Negative pressure is now applied. Chignon is created by lowering the pressure to –
0.2 kg/sq cm (for metal cup) for about 30 seconds to one minute.
8. Once the cup has been attached to the head by the first phase of low vacuum, its
position must be checked. It is also important to run the finger round the cup to make
sure that there is no maternal tissue caught. Further increase of the vacuum to the
maximum can only be carried out after all these have been checked.
9. After a vacuum of -0.8 kg/ sq cm has been achieved for one minute, check again that
no maternal tissue is caught.
10. Traction is applied only during contractions, in conjunction with maternal expulsion
efforts. Oxytocin may be infused to augment the contractions. Traction is
discontinued between contractions and the fetal heart beat is auscultated.
11. Traction is usually applied with the operator’s right hand, in the seated position.
12. The thumb of the left (non-pulling) hand puts pressure against the dome of the cup.
The index and the middle fingers of the same hand rest on the scalp at the periphery
of the cup to monitor the descent.
13. The chain must be perpendicular to the surface of the cup. Oblique traction will tend
to detach the cup.
14. Traction is applied smoothly throughout the contraction, refrain from applying jerky
traction. The initial direction is downward and outward, gradually changing to
upward and outward when crowning occurs.
15. Vacuum is released once the head is delivered.

Precautions
1. If there is a hissing sound, the traction is momentarily stopped to allow the vacuum
to build up.

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2. If the cup slips, only one re-application is allowed if the operator is satisfied that
there is no disproportion.
3. The cup should not be applied for more than 15 minutes to prevent pressure necrosis
of the scalp.
4. The finger-thumb position of the non-pulling hand serves to inform the operator that
the head, not just the scalp is descending. It also helps to prevent complete
detachment or the cup.
5. If there is no satisfactory descent within 3 pulls, the procedure should be abandoned.
6. If only the scalp descends but not the skull (known as a negative pull), the procedure
should be abandoned as subaponeurotic hemorrhage is likely to occur.
7. Parents should be reassured that the chignon will subside within 48 hours.

Direction of vacuum extractor traction

a) Outward and posteriorly b) Outward and horizontally c) Outward and anteriorly

Diagram Direction of pull

Outwards and posteriorly

Outward and horizontally

Outward and anteriorly

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Post-procedure management
Instrumental assisted vaginal delivery is associated with significant morbidity to a mother
and her baby. Therefore, there should be an appropriate post-procedure management
which includes:

Monitoring for both mother and newborn

Mother should be monitored in labour room for potential complications from
instrumental delivery:
1. Postpartum haemorrhage
a. Patient should be managed actively during second stage with oxytoxics to
reduce risk of PPH.
b. She should be monitored for per vaginal bleeding with pad chart; size and
tone of uterus should be checked regularly.
2. Perineal examination to look for vaginal or cervical tear/haematoma.
Newborn should be placed under the care of paediatrician to watch out for complications
like subaponeurotic haemorrhage.

Documentation
Proper documentation is crucial in instrumental delivery. A proforma should be designed
to accommodate all the necessary information which includes
1. Indication for instrumental delivery
2. Assessment prior to procedure (to ensure prerequisites are fulfilled)
3. The process of instrumental delivery
4. Name of accoucher and assistant as well as supervisor
5. Number of traction
6. Timing of all steps of procedure
7. Outcome of procedure (baby’s APGAR, cord blood pH)
8. Findings of perineal examination
9. Blood loss
10. Post-procedure care

Debriefing
Instrumental delivery can be a traumatic experience to the couple involved. They
deserved to be informed on the indication of instrumental delivery, the process and the
outcome. They need to be updated on the condition of their newborn as well.

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HYPERTENSIVE DISORDERS OF PREGNANCY

Objectives

 Understand the definition and classification of hypertensive disease in pregnancy

 Able to recognize severe preeclampsia and eclampsia
 Understand the principle of management of preeclampsia/eclampsia

Definition and classification of hypertensive disorders of pregnancy

Definition
Hypertension in pregnancy is defined as blood pressure reading of  140/90 mmHg on at
least two occasions, taken at least 15 minutes apart.

Severity BP range
Mild 140 – 149/90 – 99 mmHg
Moderate 150 -159/100 – 109 mmHg
Severe Systolic BP of  160 mmHg; Diastolic BP of  110 mmHg (2 reading at
15 minutes interval);
Hypertensive emergency when systolic BP  180 mmHg

Classification of hypertensive disorders of pregnancy

Based on International Society of Study of Hypertension in Pregnancy (ISSHP)

Classification
Gestational hypertension
Preeclampsia
Chronic hypertension
Unclassified hypertension
White-coat hypertension
Characteristics
Hypertension ≥ 20weeks; without significant proteinuria
or other characteristics that define preeclampsia
Hypertension ≥ 20weeks; with significant proteinuria or
other characteristics that define preeclampsia
Pre-eclampsia can be de novo or superimposed on
chronic hypertension
Hypertension < 20 weeks or exists before pregnancy
Hypertension >20 weeks with no BP recorded before 20
weeks
The office/clinic blood pressure measurements are
elevated but home blood pressure measurements are
normal

Pre eclampsia
Based on the Revised ISSHP definition of Pre-eclampsia (2014)
Hypertension developing after 20 weeks of gestation and the co-existence of the
following new onset conditions:
1. Proteinuria of 300 mg/day or urine protein/creatinine ratio of 30 mg/mmol
2. Other maternal organ dysfunction:
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a. Renal insufficiency (creatinine ≥ 90 mmol/L)

b. Liver involvement (elevated transaminases and /or severe right upper
quadrant or epigastric pain)
c. Neurological complications (eclampsia, altered mental status, blindness,
stroke or more commonly hyperreflexia when accompanied by clonus,
severe headaches and persistent visual scotomata)
d. Haematological complications (thrombocytopaenia, DIC, haemolysis)
3. Uteroplacental dysfunction
a. Fetal growth restriction
4. Others – pulmonary oedema, placental abruption, oliguria, epigastric pain/RHC
pain

*PROTEINURIA IS NO LONGER REQUIRED TO DIAGNOSE PREECLAMPSIA

Complications of Preeclampsia/eclampsia
It is of utmost importance to be able to recognize preeclampsia/eclampsia as it is
associated with significant maternal and fetal morbidities

Maternal  Hypertension
complications  Risk of cerebrovascular accident
 Renal failure
 Liver failure
 DIVC
 Pulmonary oedema (ARDS)
 Pulmonary haemorrhage
 Placental abruption
 Eclampsia (risk of aspiration pneumonia)
Fetal  Prematurity
complications  IUGR
 Respiratoy distress syndrome (RDS)
 Acute fetal distress (secondary to lowering BP with
antihypertensive agents)
 Intrauterine death

Assessment of patient with pre-eclampsia

A. Full history including

 Symptoms of impending eclampsia
 Headache
 Blurring of vision
 Epigastric pain
 Potential complication from severe preeclampsia
 Shortness of breath

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 Per vaginal bleeding and abdominal pain to suggest placenta

abruption
 Fetal movement
B. Full examination including
 BP & PR
 General examination – CVS, lungs and abdomen examination
 Reflexes (can be brisk)
C. Investigation

Investigation Parameters Justification

1. Full Blood Count  Haemoglobin  Increased due to intravascular
level depletion
 Decreased due to haemolysis
from HELLP
 Platelet level  Decreased in HELLP (associated
with poor maternal outcome)
2. Renal function  Serum  Increased due to renal
creatinine impairment/ haemoconcentration
(associated with adverse maternal
outcome)
3. Serum uric acid -  Increased in uric acid is
associated with adverse maternal
and fetal outcome.
 Can be due to dehydration
 *An isolated increased uric acid
does not indicate delivery
4. Liver function test  Aspartate  Level of transaminases increase in
aminotransferase cases of HELLP
(AST)  It is associated with adverse
 Alanine maternal outcome
aminotransferase
(ALT)
5. Coagulation  INR and aPTT  Deranged in cases of placenta
profile abruption and DIVC
(not routine –
indicated in severe
pre-eclampsia)
6. Lactate -  Increase with haemolysis
dehydrogenase
(LDH) - indicated
in cases of HELLP

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Management of Severe Preeclampsia

General principles of management of severe hypertension:
1. Control of blood pressure
2. Prevention/control of eclampsia
3. Monitoring (maternal and fetal)
4. Fluid management
5. Delivery

Control of blood pressure

The major considerations in controlling blood pressure in severe hypertension:
1. Oral Nifedipine and parenteral Labetalol are the agents of choice when BP is 
160/110 mmHg as both are equally effective.
a. However, when systolic blood pressure is  180 mmHg, blood pressure
should be controlled more rapidly with intravenous antihypertensive
agents.
b. Parenteral hydralazine is used when labetolol is contraindicated or fails to
control BP.
c. Intravenous Glyceryl trinitrate (GTN) can be considered in case of
resistant hypertension.
2. Lower BP to non-severe level instead of normalization of blood pressure.
Therefore, target BP should be 140 – 159/90 – 109 mmHg to avoid maternal
hypotension and thus, compromising uteroplacental perfusion.
a. Blood pressure should be monitored regularly at interval of 5 – 10 minutes
to identify maternal hypotension.
3. Close fetal monitoring is recommended while trying to control the BP via
continuous CTG monitoring or if the gestation is less than 28 weeks, fetal heart
rate should be checked at 5 – 10 minutes interval with daptone.

Oral Nifedipine

1. Indication: SBP = 160 – 180 mmHg or DBP  110 mmHg or when parenteral
labetalol is not available
2. Tablet Nifedipine can be given at the dose of 10 mg; A repeated dose of 10 mg
can be given 30 minutes later if BP is still  160/110 mmHg.
3. A total dosage given should not exceed 20 mg (a total of 2 doses)
4. Side effects include maternal tachycardia and headache

Parenteral antihypertensives – Labetalol and Hydralazine

Bolus doses
IV Labetalol IV Hydralazine
Indications BP  160/110 mmHg BP  160/110 mmHg when
parenteral Labetalol is
contraindicated or parenteral
Labetalol fails to control BP
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Concentration 1 ampoule = 25 mg/ 5 ml (5mg/ml) 1 ampoule = 1 ml (20 mg/ml)

Preparation Dilution is not necessary; Use pure Withdraw 1 ampoule (20 mg) of
form with concentration of 5 mg/ml hydralazine + 19 ml of normal saline
= 20 mg/20 ml (1 mg/ml)
Bolus dose (s)  1 dose – 25 mg (5 ml); given in  1st dose – 5 mg (5 ml); given in 2
st

2 minutes minutes
 2nd dose – 50 mg; given in 2  2nd dose – 5 mg (5 ml); given in 2
minutes if BP is  160/110 minutes if BP is  160/110
mmHg 30 minutes after the 1st mmHg 30 minutes after the 1st
bolus bolus
 *3rd dose – 50 mg may be given  *3rd dose – 5 mg (5 ml) may be
if SBP is  180 mmHg 30 given if SBP is  180 mmHg 30
minutes after the 2nd bolus and minutes after the 2nd bolus and
rapid BP controlled is desired rapid BP controlled is desired
*In hypertensive emergency (SBP  180 mmHg) or in situation where rapid BP
controlled is desired, 3rd bolus dose of intravenous labetalol/hydralazine may be given
at the discretion of managing specialist.

Infusion doses
IV Labetalol IV Hydralazine
Indication BP  160/110 mmHg after 2 or 3 BP  160/110 mmHg after 2 or 3
boluses of intravenous labetalol boluses of intravenous hydralazine
Concentration 1 ampoule = 25 mg/ 5 ml (5mg/ml) 1 ampoule = 1 ml (20 mg/ml)
Preparation Dilution is not necessary Withdraw 2 ampoules (40 mg) of
Withdraw 10 vials (total of 250 mg) hydralazine + 38 ml of normal
into 50 cc syringe saline = 40 mg/40 ml (1 mg/ml)
Titration  Starting dose is 20 mg/H (4 ml/H)  Starting dose is 1 mg/H (1
 Titration should be done every 30 ml/H)
minutes to achieve target BP  Titration should be done at the
 Titration of dose: rate of 1 mg/H (1 ml/H) every
o 20 mg/H (4 ml/H) 30 minutes up to maximum rate
of 10 mg/H (10 ml/H) to
o 40 mg/H (8 ml/H) achieve target BP
 Target BP: 140 – 150/90 – 109
o 80 mg/H (16 ml/H) mmHg
 Maintain the dose if target BP is
o 160 mg/H (32 ml/H) achieved
 Target BP: 140 – 150/90 – 109  Titrate down the dose if BP is <
mmHg target BP
 Maintain the dose if target BP is
achieved
 Titrate down the dose if BP is <
target BP
Hydralazine should be considered if BP is uncontrolled after infusion of IV labetalol at
maximum rate of 160 mg/H (32 ml/H)

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IV Labetalol IV Hydralazine
Contraindications  Bronchial asthma  Maternal tachycardia
 Congestive heart failure
 Heart block
Side effects  Maternal bradycardia  Maternal hypotension and
 Neonatal bradycardia – tachycardia
therefore, neonatal unit needs  Headache and dizziness
to be informed if the woman is
given parenteral labetalol.

Parenteral antihypertensives – Glyceryl Trinitrate

Infusion doses
Infusion pump Syringe pump
Indication In resistant hypertension when BP is still uncontrolled with IV Labetalol
and Hydralazine
Concentration 1 ampoule = 10 ml (50 mg/10 ml)
Preparation 50 mg (10 ml) + 240 NS/D5% = 10 mg (2 ml) + 48 ml NS/D5% = 200
200 g/ml g/ml
Infusion rate  Starting dose is 5 – 10 g/min (1.5 – 3 ml/H)
 Titration should be done at the rate of 5 – 10 g/min (1.5 – 3 ml/H)
every 5 - 10 minutes up to maximum rate of 200 g/min (60 ml/H)
to achieve target BP
 Target BP: 140 – 150/90 – 109 mmHg
 Maintain the dose if target BP is achieved
 Titrate down the dose if BP is < target BP
Monitoring BP measurement every 5 – 10 minutes to detect maternal hypotension
Continuous CTG monitoring or auscultation with daptone every 5 minutes

Prevention and/or control of eclampsia

Magnesium sulphate (MgSO4) is the agent of choice in prevention of eclampsia or
control of seizure during eclampsia. It is associated with almost 50% risk reduction
when used as eclampsia prophylaxis. MgSO4 can be given via intravenous route or
intramuscular route.

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Indications for Magnesium Sulphate:

1. Eclampsia (as treatment to control seizure)
2. In severe pre-eclampsia as defined by the following (after discussion with O&G
specialist):
3. Severe hypertension associated with any of the following;
 Significant proteinuria of ≥ 2+
 Symptoms of impending eclampsia: headache, blurring of vision,
epigastric pain, nausea or vomiting
 Complications from severe pre-eclampsia: HELLP syndrome, acute
pulmonary oedema, placenta abruption, intrauterine death
4. As fetal neuroprotection for woman whose delivery is indicated at ≤ 32 weeks

Intravenous Magnesium Sulphate

Loading dose Maintenance dose

Infusion pump Syringe pump
Dose 4g 1 g/H 1 g/H
Concentration 1 ampoule = 2.47 g/5 1 ampoule = 2.47 g/5 ml 1 ampoule = 2.47 g/5 ml
ml
Preparation Withdraw 8 ml (4g) of Withdraw 10 ampoules Withdraw 2 ampoules (5
MgSO4 + 12 ml of (50 ml) of MgSO4 + g/10 ml) of MgSO4 +
normal saline = 20 ml 450 ml of normal saline 40 ml of normal saline =
5 g/50 ml (1 g/10 ml)
Administration To give 4g MgSO4 in Infusion rate – 21 ml/H Infusion rate – 10 ml/H
slow bolus for 15 – 20 (1 g/H) (1 g/H)
minutes Continue infusion of Continue infusion of
MgSO4 for 24 hours MgSO4 for 24 hours
after delivery or last after delivery or last
seizure, whichever seizure, whichever
occurs later occurs later
In cases where seizure occurs after administration of MgSO4, a further bolus of 2 – 4 g MgSO4
can be given with close monitoring of Mg level. Serum magnesium can be taken before the
repeated bolus MgSO4 if the situation allows.

Intramuscular Magnesium Sulphate

Loading dose Maintenance dose

Dose Total of 10 g (5 g each buttock) 5 g every 4 hours
Concentration 1 ampoule = 2.47 g/5 ml 1 ampoule = 2.47 g/5 ml
Preparation Withdraw 2 ampoules (5 g/10 ml) of Withdraw 2 ampoules (5 g/10 ml) of
MgSO4 + 1ml of local anaesthesia MgSO4 + 1ml of local anaethesia
Administration Deep intramuscular injection into Deep intramuscular injection into
each buttock alternate buttock every 4 hourly until
24 hours after delivery or last

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seizure, whichever occurs later

In cases where seizure occurs after administration of MgSO4, a further bolus of 5 g
intramuscular MgSO4 can be given with close monitoring of Mg level. Serum magnesium can be
taken before the repeated bolus MgSO4 if the situation allows.

Maternal and fetal monitoring

Maternal monitoring

Monitoring for MgSO4 toxicity

Magnesium sulphate can potentially cause cardiorespiratory depression. Therefore the
woman needs to be monitored for signs and symptoms of MgSO4 toxicity

Parameters Interval of monitoring Target

Blood Pressure 15 minutes 140 – 150/90 – 109 mmHg
Pulse rate 15 minutes  60 bpm
Respiratory rate Hourly  16 breaths per minute
Urine output Hourly  30 ml/H or  100 ml/4 hours
Deep tendon reflex of knee Hourly Presence of reflexes
*Monitoring of magnesium level is NOT routine in women receiving MgSO4. However, if
there is suspicion of magnesium toxicity, the Mg level should be checked. In cases where
fit occurs while the woman is on MgSO4, serum Mg level can be taken before a repeat
bolus of MgSO4 if feasible.

Management of potential MgSO4 toxicity

1. Urine output < 100ml/ 4hour:

a. Assessment
 Hydration status of the woman; Pulse volume
 Examination of lungs and review fluid balance.
 Check reflexes and respiratory rate to ensure there are no signs of toxicity
 Send BUSE, serum creatinine and serum magnesium level stat and trace
results.
b. Management
 If the woman appears dehydrated, may consider fluid challenge with 500mls
normal saline over 1hour after discussion with specialist
 If unable to do serum magnesium levels, send BUSE and serum creatinine but
reduce the maintenance dose to 0.5mg/hour
 If serum creatinine is normal and magnesium level is within therapeutic range
then continue MgSO4 at 1 g/H.
 If serum creatinine is normal and magnesium level is raised above therapeutic
range, reduce the dose by half to 0.5 g/hour
 If serum creatinine is raised or serum magnesium level is above the

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therapeutic range then STOP the infusion

 Once urine output improves, the maintenance dose should be resumed at 1g/H

2. Absence of patellar reflex:

a. Stop MgSO4 infusion
b. May consider restarting infusion at lower dose when reflexes return
c. Send blood for BUSE, Serum Creatinine and serum magnesium if available

3. Respiratory depression:
a. Stop infusion
b. Maintain airway, nurse patient in recovery position

4. Respiratory arrest:
a. Stop infusion
b. Maintain airway with intubation and ventilation (till return of spontaneous
respiration)
c. Slow IV bolus of 10 ml of calcium gluconate 10% over 10 minutes

ANTIDOTE FOR MGSO4 TOXICITY:

 1gm Calcium gluconate (10ml of 10% solution) given IV slow bolus (10 min).
 If level of Mgnesium is > 3.5 mmol/L, cease infusion and consult Obstetrician

Fetal monitoring
1. Ultrasound for fetal biometry, liquor volume with +/- umbilical artery Doppler if
available
a. If delivery is not indicated, fetal growth should be monitored 2 weekly
2. Continuous electronic fetal heart monitoring especially during control of BP; if
electronic fetal monitoring is not available, fetal heart rate should be monitored
with daptone at 5 – 10 minutes interval.

Fluid management
Women with pre-eclampsia are likely to have intravascular depletion. However, they are
also prone for loss of fluid into extracellular space. This is due to reduced intravascular
oncotic pressure and compounded by increase endothelial permeability due to endothelial
injury.

General principles of fluid management are as below:

1. Total fluid given to women with severe hypertension – 83 ml/H of crystalloid
(approximately 2L/day).
2. Strict input and output charting.
3. Fluid challenge, when indicated, should be done with careful assessment of the
woman’s hydration status and after consultation with specialist.
4. Fluid restriction is best avoid except in cases of proven fluid overload, i.e. in
acute pulmonary oedema. Women with fluid overload should be management in
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high dependency unit/intensive care unit with co-management from anaesthetist

and physician.
5. Diuretics should NOT be given in the event of oliguria unless there is evidence of
acute pulmonary oedema.

Delivery
The definitive management of severe hypertension in pregnancy is the delivery of
placenta

Gestational age
≥ 37 weeks Delivery is indicated; mode of delivery is dependent on
maternal and fetal condition
34 – 36+6 weeks Delivery may be indicated and decision for delivery should
be made in consultation with specialist.
Antenatal corticosteroids may be considered. However,
delivery should NOT be delayed for completion of
corticosteroids if urgent delivery is indicated.
< 34 weeks Decision for delivery should be made in consultation with
specialist
Antenatal corticosteroids should be administered.

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Eclampsia
Eclampsia is an obstetric emergency. Any seizure occurring in pregnant women NOT due
to other causes is considered eclampsia unless proven otherwise. The seizure activity may
be associated with pre-existing pre eclampsia or it may the first presentation of the
condition.

38% of the fits occur antenatally, 18% intrapartum and the remaining 44% postpartum
usually within the first 24-48 hours after delivery.

Management of eclampsia is essentially similar to that of severe preeclampsia. In

addition, resuscitation and control of seizure should be of priority.

Management of eclampsia
1. Call for help! (INITIATE RED ALERT)
2. Resuscitation
 Ictal phase: left lateral position and oxygen supplementation
 Post-ictal: assessment of response, protect airway, assess breathing and
circulation (may need maternal cardiorespiratory resuscitation if there is
absence of normal breathing)
3. Secure at least 2 intravenous lines.
4. Abort seizure with MgSO4 as discussed in previous section.
5. If the woman develops another fit during or after loading dose, administer another
2 – 4 gm of IV MgSO4.
6. Monitoring in HDU labour ward/ICU
7. Start parenteral anti- hypertensive if SBP ≥ 160 mmHg or DBP ≥ 110mmHg
8. Monitoring according to protocol.
9. Total fluid 2L/24 hours (80ml/hour)
10. Monitor fetus
11. Plan for delivery after patient is stabilized
12. If eclampsia recurs, to refer to anaesthetist for intubation and cerebral
resuscitation in ICU

Diazepam regime
1. Diazepam is no longer the drug of choice for the management of
Eclampsia
2. It can still be used if magnesium sulphate is not available or seizure continue
despite administration of 2nd loading dose of MgSO4 (by which time,
anaesthetic team should be alerted)
3. Give slow bolus of IV diazepam 10 mg over 5 minutes
4. Repeat 10mg diazepam by slow bolus if convulsions still persists

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HELLP Syndrome
HELLP Syndrome is a subset of pre-eclampsia/ eclampsia with biochemical evidence of
haemolysis, elevated liver enzyme and low platelet counts. It is a potentially lethal
condition which will improve following the delivery of the fetus. However, be caution that
the disease process reaches its nadir 24 to 48 hours after delivery. Clinical findings of pre-
eclampsia such as diastolic hypertension, proteinuria and non-dependant oedema may not
be present. Diagnosis at times is made after delivery (20%). This condition needs to be
differentiated from thrombotic thrombocytopenic purpura.

Diagnosis of HELLP
Patient presents with:
1. Severe pre-eclampsia or eclampsia
2. Hemolysis
3. Hepatic dysfunction as evidenced by elevation of:
a. Lactate dehydrogenase (LDH)
b. Indirect bilirubin
c. Aspartate amniotransferase (AST)
4. Thrombocytopenia

Severity of HELLP is based on platelet count:

Class 1 < 50,000/uL
Class 2 < 100,000/uL
Class 3 < 150,000/uL

Management of woman with HELLP

1. Assessment and evaluation of patient
a. Full blood count, coagulation profile
b. Peripheral blood film
c. Electrolytes & Serum Uric acid
d. Renal profile
e. Liver function test , indirect & total bilirubin
f. Urine
2. Assessment of fetus
3. Control of blood pressure
4. Prevention of seizure - use of MgSO4
5. Consider platelet transfusion if < 50,000/uL or symptomatic and correction of
coagulopathy (FPP, cyroprecipiate) especially if patient plan for operative delivery or
in immediate post-operative period.
6. Plan for delivery - timing and mode

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Postpartum management
Postpartum period is not devoid of the complications from severe hypertension.
Eclampsia occurs most commonly during the postpartum period, especially on the first
day postpartum.
Postpartum care should include:

1. Monitoring of women in high dependency unit with continuation of MgS04 (if

started before delivery); Monitoring should be as vigilant as before delivery.
2. Adjustment of antihypertensive drugs should be done with caution; the aim
should be stopping or reducing parenteral antihypertensive with initiation of oral
antihypertensive if BP is uncontrolled. Target BP should be < 140/90 mmHg.
3. Oral antihypertensives
a. Methyldopa is best avoided during postnatal period
b. In gestational hypertension/preeclampsia, antenatal oral antihypertensive
agent can be continued if postpartum BP is > 150/100 mmHg persistently;
for women who do not receive oral antihypertensive antenatally, consider
start treatment if BP persistently > 150/100 mmHg
c. For chronic hypertension, prepregnancy antihypertensives which are safe
in breastfeeding can be started if BP is > 150/100 mmHg
d. Choice of postpartum antihypertensive agents

Safe for breastfeeding Insufficient data on safety

 Labetalol  ARBs
 Nifedipine  Amlodipine
 Enalapril  Other ACEIs except enalapril
 Captopril and captopril
 Atenolol
 Metoprolol

4. Upon discharge:
a. Advice on symptoms of impending eclampsia; emphasize compliance to
follow up and medication; risk of hypertensive disorder in subsequent
pregnancy
b. Assessment of venous thromboembolism risk
c. Communication with primary health clinics for monitoring and adjustment
of antihypertensive (BP monitoring twice per week and weekly review by
doctor; high risk cases may need more frequent monitoring)
d. Need for aspirin and calcium supplementation as prevention of
preeclampsia in next pregnancy.

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