STANDARD CLINICAL MANAGEMENT

PROTOCOLS AND FLOWCHARTS ON

EMERGENCY OBSTETRIC AND
NEONATAL CARE

2 019

Obstetrical and Gynaecological Society of Bangladesh (OGSB)

Ministry of Health and Family Welfare
Directorate General of Health Services (DGHS)
Directorate General of Family Planning (DGFP)

Directorate General of
Family Planning
OGSB
STANDARD CLINICAL MANAGEMENT PROTOCOLS AND FLOWCHARTS ON
EMERGENCY OBSTETRIC AND NEONATAL CARE a
STANDARD CLINICAL MANAGEMENT
PROTOCOLS AND FLOWCHARTS ON
EMERGENCY OBSTETRIC AND
NEONATAL CARE

2 019

Obstetrical and Gynaecological Society of Bangladesh (OGSB)

Ministry of Health and Family Welfare
Directorate General of Health Services (DGHS)
Directorate General of Family Planning (DGFP)
Supported by: UNICEF
Printed with support from Global Affairs Canada

STANDARD CLINICAL MANAGEMENT PROTOCOLS AND FLOWCHARTS ON

EMERGENCY OBSTETRIC AND NEONATAL CARE 1
Abbreviations
• ABCD Airway, Breathing, Circulation, Disability
• AMTSL Active Management of Third Stage of Labour
• ANC Antenatal Care
• APH Antepartum Haemorrhage
• BF Breast Feeding
• βhCG β Human Chorionic Gonadotrophin
• CBC Complete Blood Count
• CCT Controlled Cord Traction
• CPR Cardiopulmonary Resuscitation
• CRP C Reactive Protein
• CS Caesarean Section
• C/S Culture and Sensitivity
• D&C Dilation and Curettage
• DGHS Director General of Health Services
• DM Diabetes Mellitus
• ECD Early Childhood Development
• E&C Evacuation and Curettage
• EDD Expected Date of Delivery
• EmONC Emergency Obstetric & Neonatal Care
• FHR Fetal Heart Rate
• FD Foetal Distress
• GOB Government of Bangladesh
• HR Heart Rate
• HTN Hypertension
• HVS High Vaginal Swab
• HLD High Level Disinfection
• IUD Intrauterine Death
• IV Intravenous
• IP Infection Prevention
• LMP Last Menstrual Period
• MBS Modified Bishops Score
• MDG Millennium Development Goal
• MMR Maternal Mortality Ratio
• MNCRH Maternal and Neonatal Care & Reproductive Health
• MO & HMO Medical officer & Honorary Medical officer
• MVA Manual Vacuum Aspiration
• MgSo4 Magnesium Sulphate
• NGO Non-Government Organization
• NS Normal Saline
• OGSB Obstetrical &Gynaecological Society of Bangladesh
• PAC Post Abortion Care
• PE Pre-eclampsia
• PNC Postnatal Care
• PPH Post-partumHaemorrhage
• POC Product of Conception
• POD Pouch of Douglas
• PROM Premature Rupture of Membrane
• PT Pregnancy Test
• PV Per vaginal
• RL Ringer’s Lactate
• RTI Reproductive Tract Infection
• SKS Skin to Skin Contact
• STD Sexually Transmitted Disease
• TB Tuberculosis
• TT Tetanus Toxoid
• USG Ultrasonography
• UNICEF United Nation International Children Emergency Fund
• VVF Vesico Vaginal Fistula
• WHO World Health Organization

2 STANDARD CLINICAL MANAGEMENT PROTOCOLS AND FLOWCHARTS ON

EMERGENCY OBSTETRIC AND NEONATAL CARE
Introduction
Reducing childbirth associated mortality remains a major challenge to Bangladesh health system. Since 1990, there has
been a significant reduction of maternal and child mortality. Despite significant progress, Bangladesh still has a very high
level of maternal and child mortality in compared to many other developing countries. Efforts to curb the rate further have
been directed at increasing the coverage of skilled birth attendance including midwives especially in facility setting. With
the increasing coverage and utilization of health service, quality of care has also become an important avenue to end
preventable morbidity and mortality. The risk of maternal and perinatal complications and its sequelae are well understood
through continuous research and generation of new knowledge.

The complications during pregnancy and childbirth can happen without warning and can strike any women at any time. A
special care known as Emergency Obstetric care is required by woman once she develops any kind of complication during
pregnancy, delivery and postpartum period to save her life. At present comprehensive emergency obstetric care services
are provided in all medical college hospitals, 58 district hospitals, 132 upazila health complexes and 69 MCWC at district
& upazila level with 2 national level institutions at Azimpur (MCHTI) and Mohammadpur (MFSTC) at Dhaka and in different
private and NGO health facilities.

The development of service delivery guidelines and implementations of clinical protocols are vital part of the effort to
standardize practices and improve the quality of services. Evidence based service delivery guidelines and protocols provide
a foundation and guidelines for program planners’, trainers and researchers. Clinical protocols ensure quality in service
delivery, teaching and training and at the same time provides safe guards for providers and managers against any medico-
legal issues. Clinical protocols are the detailed outline for health service providers for case management with integrated
knowledge, skills and attitude. Development and or revising national or institutional protocols and guidelines for reproductive
health services is a complex process requiring the commitment and input of a multidisciplinary team. The process and
protocols should have the authorization of policy makers to replace the previous protocols and to ensure uniform practice
of newer one.

Obstetrical and Gynaecological Society of Bangladesh (OGSB) is working in the area of development of different teaching
and training aids including curricula, protocols and guidelines. OGSB and Government of Bangladesh has developed for
this emergency obstetric care for doctors with the support of UNICEF, Dhaka, Bangladesh which have been approved by
the Curriculum Review Committee of DGHS, Ministry of Health and Family Welfare.

It has been observed during the monitoring process of EmONC services in different health care facilities that these protocols
are not used properly by the health care providers in the facilities. Reasons behind this include protocols are in booklet
form, carrying too many information and not very user friendly. So use of protocols in daily practices is almost non-existing
in majority of facilities including the medical colleges.

So, considering this, OGSB decided that based on the information supplied in these protocols, modification and upgrading
could be done to make them user friendly and at the same time several flow charts could be prepared in poster forms to
be displayed in different service delivery rooms (labour room, eclampsia, Operation Theater etc.). The flow charts will be in
easy and simple language with relevant information arranged chronologically in step wise manner.

STANDARD CLINICAL MANAGEMENT PROTOCOLS AND FLOWCHARTS ON

EMERGENCY OBSTETRIC AND NEONATAL CARE 3
Protocols and guidelines are essential to ensure quality service delivery. At the same time implementation needs efforts
and support. For implementation OGSB has also arranged training of trainers of different health care facilities regarding the
content and use of protocols and flow charts. These trainers could facilitate the dissemination and use of these protocols and
flowcharts in different health care facilities and training of service providers. On the basis of evaluation and feedback from
the users, respond to new information and changing needs an ongoing process of updating and improving the protocols will
be continued from time to time.

Protocol development:

A project proposal was made to get support from UNICEF, Bangladesh for upgrading and modification of existing protocols
and development of flowcharts on emergency obstetric and neonatal care (EmONC). The whole process of upgrading the
protocols was a joint effort by the member of the core committee, working group committee, EC members of OGSB, relevant
experts of different medical colleges and other relevant experienced persons.

Initially draft protocols and flow charts were prepared by different working groups formed by the core committee. To review
the protocol, a series of expert consultation meeting was arranged among all the members such as core committee, working
group committee, EC members of OGSB, relevant experts of medical colleges and other relevant experienced persons.
The draft protocols and flow charts were repeatedly reviewed and rechecked. The reviewed protocols and flow charts were
finally checked by small group of expert professionals. After finalizing the standard clinical management protocol it will be
disseminated to the representative from DGHS, Ministry of health, UN Agencies, Development Partners and NGOs.

The upgrading and modification of the standard clinical management on EmONC protocol was done by following several
steps as shown in Figure 1.

Development Reviewed and Changes

of the core rechecked the made to the
committee protocol protocol

Opinion on
Upgrade and
protocol until a Incorporate
modify the existing
consensus was changes
protocol
reached

Modified protocol
Expert Finalized
shared with small
consultation the clinical
group of expert
meeting arranged protocol
professional

Figure 1: Steps for upgrading and modification of the Standard Clinical Management on EmONC protocol

4 STANDARD CLINICAL MANAGEMENT PROTOCOLS AND FLOWCHARTS ON

EMERGENCY OBSTETRIC AND NEONATAL CARE
Guideline of using the protocols

1. The protocols of the Standard Clinical Management on EmONC have been developed for the doctors working in
comprehensive EmON Ccenters with emphasis on management of normal labour and common obstetric emergencies.
This is also an attempt to standardize clinical practice and to improve case management and training. It will also help
in rational use of drug, uniformity of care, accountability along with supervision and monitoring. If practiced under a
standard guideline, these protocols shall also offer safeguard to the service providers against medico-legal issues.
2. These protocols are developed taking help of literature review and evidence based practices and made suitable for wide
variety of doctors. They can use these according their level of expertise and available facilities.
3. There are 28 protocols; There are provisions of management of a normal delivery but there are also guidelines for
managing all most all type of deviations from normal. In each protocol there is clear instruction for diagnosis, management,
getting help when necessary and referral. The first protocol is developed on Behavior Change Communication.
4. This protocol has been updated using international guideline e.g. WHO, NICE & RCOG guideline with references.
5. It is not possible to cover all aspect of management of a particular case in this guideline for various limitations. Hopefully
it will satisfy the need of the majority.
6. It is recommended that every trainee (Registrar/Asst. Reg./MO/HMO/EmONC/internee) should get a copy of this booklet
before starting training from the institute.
7. These protocols should be made available at the delivery room, eclampsia rooms and other service delivery room for
proper utilization
8. Head of the Dept. of all institutes and consultant of District Hospital should arrange to display the flow charts on service
delivery rooms.
9. Each training institutes should arrange two orientation courses for the new trainees twice in a year and provide training
for using these protocols on daily practice before starting training.

STANDARD CLINICAL MANAGEMENT PROTOCOLS AND FLOWCHARTS ON

EMERGENCY OBSTETRIC AND NEONATAL CARE 5
CONTENTS

1 I treat Patients and their families in the way I would like to be treated-protocol 8

2 Antenatal Care (ANC)-protocol 9

3 Normal labour and Child Birth practices-Protocol & Flow Chart 12

3.1 Care throughout Labour 13

3.2 Rapid Initial Assessment 14

3.3 Diagnosis of Labour- History taking and examination 15

3.4 Normal labour Management 17

3.5 Use of Partograph in Labour 22

4 Induction and augmentation of labour-protocol 24

5 Unsatisfactory progress of labour-flow chart and protocol 34

6 Foetal distress- protocol & flow chart 37

7 Shoulder dystocia- Protocol & flow chart 39

8 Prolapse of Umbilical cord- Protocol & flow chart 42

9 Vaginal Delivery after Caesarean Section- Protocol & flow chart 44

10 Labour Analgesia Para cervical block – Protocol 47

11 Postnatal Care (PNC)- protocol flow chart 51

12 Immediate or Routine Care at Birth-flowchart 55

13 Management of Perinatal Asphyxia -flow chart 56

14 Management of low birth weight babies 58

15 Breastfeeding-flow chart 63

6 STANDARD CLINICAL MANAGEMENT PROTOCOLS AND FLOWCHARTS ON

EMERGENCY OBSTETRIC AND NEONATAL CARE
16 Infant and young child feeding (IYCF)-Protocol 65

17 Antepartum haemorrhage- protocol 67

18 Postpartum haemorrhage -flow chart and protocol 70

19 Management of Ruptured uterus- Flow chart 74

20 Obstetric Shock- Flow chart 75

21 Premature Rupture of Membrane (PROM)- Protocol & flow char 76

22 Preterm labour 78

Hypertensive disorder of pregnancy: Management protocol Severe PE,

23 80
Eclampsia- Flow chart and protocol

24 Protocol for Gestational Diabetes Mellitus 94

25 Protocol of Jaundice in Pregnancy 98

26 Anaemia in pregnancy 104

27 Intra Uterine Growth Restriction (IUGR)/Fetal Growth Restriction (FGR) 107

28 Pain and bleeding in early pregnancy (PUL)-management flow chart 110

Vaginal Bleeding in Early Pregnancy (Miscarriage/Abortion)-

29 111
Protocol & flow chart

30 Vaginal bleeding in early pregnancy (mole/ectopic)- protocol & flow chart 113

31 Septic Abortion- Protocol & flow chart 118

32 Post Abortion Care (PAC)- Flow chart 121

33 Antibiotic therapy- Protocol 122

34 Infection prevention practices- Protocol 123

STANDARD CLINICAL MANAGEMENT PROTOCOLS AND FLOWCHARTS ON

EMERGENCY OBSTETRIC AND NEONATAL CARE 7
1: I Treat Patients and Their Families in the Way I
Would Like to be treated

 By Using Communication Techniques That Show Respect and Care

• I introduce myself and address the patient by name
• I smile
• I look into the patient’s eyes when speaking
• I use understandable language
• I use a calm, respectful tone of voice
• I keep body height at same level when talking together (if patient is lying down, I sit in chair beside the bed)
• I pay attention when the patient talks
• I include the patient and family in discussions about the patient’s situation when doing bedside rounds,a
good way to educate and show respect at same time

 By Assuring privacy/Confidentiality
• I do not discuss personal details of the patient in public
• During examinations:
a. I draw curtains between beds if possible
b. I do appropriate exposure during examinations
c. Carefully expose part of body to be examined
d. Cover parts of body not being examined
e. Ask family to provide privacy by holding up cloth during examination

 By Supporting Patient’s Emotional Needs

• I observe signs of fear, anger, stress, fatigue and pain
• I allow the patient to express her feelings
• I show empathy to the patient by being kind
• I PRAISE and REASSURE patient’s efforts

 By Respecting a Patient’s Dignity

• I always explain what I am doing before touching; such as during breast, abdominal and vaginal examination
• I tell the patient my findings of examination

 By Providing Guidance
• I explain what to expect during labour and birth.
• I explain what the patient and family can do during labour (Drink lots of fluids, empty bladder often, walking
during labour, positions for labour and birth)

8 STANDARD CLINICAL MANAGEMENT PROTOCOLS AND FLOWCHARTS ON

EMERGENCY OBSTETRIC AND NEONATAL CARE
2: Flow chart for Antenatal Care

Definition: It is the preventive and promotive health care for all pregnant women to ensure safe delivery and
delivery of a healthy baby and to reduce mortality & morbidity.
Schedule of ANC visit:
2016 WHO ANC model Recommended at least 8 visits, 1st within 12 weeks, 2nd – at 20 weeks, 3rd at 26 weeks, 4th -
at 30 weeks, 5th at 34 wks, 6th at 36 wks, 7th at 38 wks, 8th at 40 wks. Return for delivery at 41 wks, if not given birth.
(1 visit at 1st, 2 visit at 2nd & 5 visit at 3rd trimester)
Ideal: Once a month up to 28 weeks, (2) Every 2 weeks up to 36 weeks, (3) Every week up to labour.

But GoB using at least 4th visit

First visit: within 16 weeks Second visit: 24-28 weeks Third visit: 32 weeks Fourth visit: 36-38 weeks

Goals - Confirm pregnancy and calculate - Assess maternal and fetal - Assess maternal and fetal - Assess maternal & fetal
expected date of delivery (EDD) well being. well being. wellbeing.
- Register pregnant women - Exclude pregnancy induced - Exclude pregnancy induced - Exclude PIH, anaemia,
- Screening women for routine hypertension (PIH), anaemia, hypertension (PIH), anaemia, multiple pregnancy, mal-
ANC or more specialized care. multiple pregnancies. IUGR, multiple pregnancies. presentation.
- Screen, treat and give preventive - Give preventive measures. - Give preventive measures. - Give preventive measures.
measures. - Review and modify birth and - Review and modify birth - Review and modify birth and
- Develop a birth and emergency emergency preparedness plan. and emergency plan. emergency plan.
plan. - Adequate weight gain - Adequate weight gain - Advice and counsel.
- Advice and counsel. - Advice and counsel - Advice and counsel. -Total weight gain (minimum
9 kg through pregnancy)

Tasks: Always conduct initial rapid assessment and management for signs of emergency, give appropriate treatment, and refer to hospital if needed

History o Menstrual History - Assess significant symptoms - Assess significant - Assess significant
(ask, check - Cycle - Check record for previous symptoms-RA symptoms.
records) - Regular/ Irregular complications and treatments - Check record for previous - Check record for previous
- LMP during the pregnancy. complications and complications and
- EDD - Re- categories (if needed) treatments during the treatments during the
o H/O previous pregnancy: pregnancy. pregnancy.
- Para - Re- categories (if needed) - Re- categories (if needed)
- Gravida
- Abortion /Still birth/ IUD
- Age of last child
- Type of delivery
- Place of delivery
- Term/pre-term/post-term
- Complication during last
pregnancy Rapid Assessment- (RA)
o ANC- of index pregnancy 1. Convulsion
- H/O Medication 2. Bleeding
o Family History: 3. Fever
- H/O DM, HTN
o H/O Medical disorder:
- Heart disease, Renal disease,
Asthma, Diabetes, Jaundice,
STI, TB,
o H/O TT vaccination
- Assess significant symptoms.
Take psychosocial history.
- Confirm pregnancy and calculate
expected date of delivery (EDD).
- Categories all women (in some
cases after test results)

STANDARD CLINICAL MANAGEMENT PROTOCOLS AND FLOWCHARTS ON

EMERGENCY OBSTETRIC AND NEONATAL CARE 9
 Examination Complete general examination: - Weight Pulse, Blood -Weight Pulse, Blood - Weight, Blood pressure,
(look, listen, - Height, Weight, BMI pressure, Anaemia, Jaundice, pressure, Anaemia, pulse, Anaemia, Jaundice,
feel) - Pulse Edema, Jaundice, Edema, Edema, respiratory distress
- Blood pressure - Fetal growth and movements - Uterine height - Fetal growth and
- Anaemia, - Normal or undue movements,
- Jaundice, enlargement - Multiple pregnancy,
- Obstetrical examination - Malpresentation
- No. of pregnancy

Screening - CBC, HbsAg, VDRL - Hb%(2) - Urine R/M/E Urine R/M/E

and Tests - Urine R/M/E(2) - Urine R/M/E(2) - Hb% - Hb%
- Urine for sugar and albumin - Anomaly scan - USG(2) (if necessary) - USG(2)
- Blood grouping and Rh typing - OGTT (all cases)
- USG(2)
- OGTT (Fasting and 2 hrs after
75gm glucose): in high risk cases

Preventive - Iron and folate - Tetanus toxoid (4) - Iron and folate - Iron and folate
measures - Calcium after 12 wks - Iron and folate - Calcium - Calcium
- Intermittent preventive treatment - Calcium + Vit D - Multivitamin and minerals - Multivitamin and minerals
for malaria during pregnancy - Multivitamin/Vitamin B - Deworming (Once) - Intermittent preventive
(IPTP)3 complex and minerals - Intermittent preventive treatment for malaria during
- De-worming (if needed) treatment for malaria during pregnancy(IPTP) (3)
- Intermittent preventive pregnancy (IPTP)3 - De worming (Once) if not
treatment for malaria during - Antenatal Corticosteroids given
pregnancy (IPTP)(3) (24 to34 weeks+6 days, - Distribution of Misoprostol if
- Antenatal Corticosteroids (24 single course) 5 not given in 3rd visit
to 34 weeks+6 days, single Distribution of Tab.
course)5 Misoprostol

Treatments - Treat all problems in pregnancy as per availability of competent providers and comprehensive facilities. Refer women for treatment of
any complications, as needed.

Health - Importance of routine ANC o Check about the birth plan Check about the birth - Check about the birth
education, - Self-care at home and emergency preparedness plan and emergency plan and emergency
advice, and - Rest, avoid heavy work& lifting o Reinforcement of previous preparedness preparedness
counseling heavy weight objects counseling - Counseling on essential - Counseling on essential
- Maternal nutrition o Counseling newborn care, postnatal newborn care, postnatal
- Safer sex and healthy life style - For maternal health care, early initiation of breast care, early initiation
- Prohibition of tobacco, illicit drugs - Diet, Nutrition and fluid feeding postpartum family of breast feeding, and
- Danger signs of pregnancy and - Rest planning and birth spacing postpartum family planning
delivery complications - Ambulation - Reinforcement of previous and birth spacing -
- Birth preparedness and - Importance of ANC visit counseling Reinforcement of previous
emergency readiness - General cleanliness/ self-care - Counseling on Misoprostol counseling
- Danger signs(Maternal) - Counseling on Misoprostol
- Bowel & bladder
- Exercise
- Birth preparedness
- Postpartum family planning
- Personal hygiene
- Hand washing
o For Birth Preparedness
- Place of delivery
- Attendant& Blood donor
- Money saving
- Transport
o For newborn health
- Essential newborn care
- Immediate and exclusive
breastfeeding
- Importance of PNC visit
- Danger signs (Newborn)
- Thermal care (S2S, KMC)

1. Wt in Kg/Ht in M2, <18.5-Underweight, <17-Moderate underweight, <16-Severe Underweight, 2. When and where available, 3. Malaria endemic area, 4. If
5 doses completed then not require, 5. Antenatal corticosteroids should be given to all women at risk of iatrogenic or spontaneous preterm birth between 24
weeks 0 day and 34 weeks 6 days weeks of gestation: Inj. Dexamethasone - 6 mg intramuscularly – 4 doses 12 hourly. (Indications : PROM, Vaginal bleeding,
Hypertensive disorder-Pre-eclampsia, Preterm labour)

Note: Daily oral iron and folic acid: 30mg to 60mg elemental iron and 400 µg (0.4mg) of folic acid - 60mg of elemental iron is
equivalent to 300mg of ferrous sulfate heptahydrate, 180mg of ferrous fumarate or 500mg of ferrous gluconate.
Daily calcium supplementation: 1.5 -2gm oral elemental calcium (WHO. 2016).

10 STANDARD CLINICAL MANAGEMENT PROTOCOLS AND FLOWCHARTS ON

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Birth Planning
Birth planning is required to facilitate safe delivery and to avoid unnecessary delay in referring the patient in case of a
complication during labour.

Issue Option

Where will you deliver? Hospital/Home (Misoprostol distribution-if birth planning at

home after 32 wks)

Who will conduct your delivery? Trained/untrained birth attendant

Where will you go if there is any complication during pregnancy/delivery/after Community Clinic/UHC/Medical College Hospital/Private
delivery? Clinic/NGO Clinic

What type of transport will you use in case of emergency to reach the hospital? Ambulance/rickshaw/van/Boat/Bullock cart

Have you saved some money to bear the expenses of emergency if needed? Small savings throughout pregnancy is good enough for
meeting the expenses of delivery

Keep contact with Blood donors (at least 2) Keep contact with Blood Bank

 Explain the danger signs and symptoms of pregnancy, labour

and postpartum period
• Any P/V bleeding with/without pain before delivery or severe
bleeding after delivery.
• Extreme pallor (breathlessness, dizziness, palpitation)
• Fits/convulsions
• High blood pressure (>140/90 mm, or a rise of 30/15 mm Hg)
• Fever (persistent, >100.4.F)
• Swollen feet, hands and face
• Severe headache and or blurring of vision
• Excessive vomiting, vomits immediately after eating or
drinking for continuous 24 hours.
• Persistent abdominal pain
• Pain when urinating
• Prolonged labour-Labour pain persist for> 12 hrs
• Leakage of fluid or rupture of membrane before onset of
labour pain
• Any part other then head is coming out during delivery
• Foul smelling vaginal discharge with fever after delivery

TT Immunization
During pregnancy this vaccine is given to the mother to prevent maternal and neonatal tetanus. In first pregnancy two
doses are required. 1st dose of tetanus is to be taken between 20-32 weeks and the 2nd dose is to be taken 4 weeks
after the 1st dose (2nd dose should be taken at least 4 weeks before EDD)
• If any pregnant mothers have completed the 5 doses, She doesn’t need any TT immunization
• If she has taken 2 injections of TT in school or previous pregnancy (within 3 years)-she have to take only one injection
Reference:
1. WHO recommendations on antenatal care
apps: who.int/iris/bitstream/10665/250796/1/9789241549912
2. WHO recommendations on antenatal care for a positive pregnancy experience, 2016 p- 23,101

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3: Normal Labour and Child Birth Practices

Care throughout labour

1. Ask the woman about her expectation for labour

2. Ensure there is culture of respect in all setting for mother
3. Inform/counsel attendant of the women about her condition from time to time
4. Don’t intervene if labour is progressing normally
5. Ensure supportive one to one care
6. Never leave the woman alone
7. Encourage the woman to mobilize & adopt comfortable positions
8. Take routine hygiene measures

Recommended practice

A. Practices which are Demonstrably Useful and Should be Encouraged

Birth planning/place of birth

A personal plan to determine the place of delivery and level of care provider needed made with the pregnant
women and her husband/family

Risk Assessment
Risk assessment of pregnancy during prenatal care, throughout labour & postnatal period

Supportive Care
1. Respecting women’s informed choice of place of birth
2. Monitoring the woman’s physical and emotional well-being throughout labour and delivery, and at the end of
the birth process
3. Respecting the right of women for privacy in the birthing place
4. Empathetic support by caregivers during labour and birth
5. Respecting women’s choice of female companions during labour and birth
6. Offering oral fluids during labour and delivery
7. Non-invasive, non-pharmacological methods of pain relief during labour, such as massage, relaxation and
breathing techniques
8. Freedom in movement throughout labour
9. Encouragement of non-supine position in labour

Ensure Evidence based practice

1. Single use of disposable materials and appropriate decontamination of reusable materials during labour and
delivery
2. Use of gloves in vaginal examination, during delivery of baby and placenta
3. Careful monitoring of the progress of labour, by the use of WHO partograph
4. Fetal monitoring with intermittent auscultation of FHR ½ hourly
5. Active management of third stage of labour to prevent postpartum hemorrhage
6. Sterility in the cutting the cord, delayed cord clamping between 1-3 min. (Ref: WHO)
7. Routine examination of the placenta and the membranes
8. Early skin-to-skin contact between mother and child and support the initiation of breast feeding within 1 hour
postpartum.
9. Prevention of hypothermia of the baby

12 STANDARD CLINICAL MANAGEMENT PROTOCOLS AND FLOWCHARTS ON

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3:1 Normal Labour and Child Birth

Inappropriate practice

B. Practices which are Frequently Used Inappropriately

1. Restriction of food and fluids during labour

2. Pain control by systemic agents
3. Pain control by epidural analgesia
4. Continuous electronic fetal monitoring
5. Oxytocin augmentation in spite of uterine contraction
6. Early amniotomy in the first stage of labour
7. Directed bearing down before the woman feels the urge to bear down herself
8. Rigid adherence to a stipulated duration of the second stage of labour, such as 2 hours, if progress of labour
and maternal and fetal conditions are good.
9. Unnecessary operative delivery
10. Liberal or routine use of episiotomy
11. Routine use of Misoprostol in third stage of labour
12. Routine use of additional oxytocin (in drip) after AMTSL

Harmful practice

C. Practices which are Clearly Harmful or Ineffective and Should be Eliminated

1. Routine use of enema, pubic shaving, intravenous infusion in labour

2. Routine prophylactic insertion of intravenous cannula
3. Routine use of bladder catheterization
4. Routine use of supine position during labour
5. Administration of oxytocin for augmentation without indication and effective monitoring
6. Routine use of lithotomy position during labour
7. Repeated or frequent vaginal examinations especially by more than one caregiver
8. Sustained bearing down efforts during the second stage of labour without relaxation
9. Massaging and stretching of the perineum during the second stage of labour
10. Fundal pressure during labour
11. Routine use of ergometrine in the third stage of labour
12. Routine lavage of the uterus after delivery
13. Routine manual exploration of the uterus after delivery

First Stage of Labour: (WHO 2018)

Latent First stage: It is period of time characterized by painful uterine contractions and variable changes of cervix
including some degree of effacement and slower progressive of dilatation up to 5cm for first and subsequent labours.
Median duration of first stage of labour is 6 to 7.5hrs
Active first stage: It is a period of time characterized by regular painful uterine contractions, a substantial degree of
cervical effacement and more rapid cervical dilatation from 5cm until full dilatation for first and subsequent labours.
Median duration of active first stage is 4hrs in first labour and 3hrs in second and subsequent labour.

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EMERGENCY OBSTETRIC AND NEONATAL CARE 13
3.2: Normal Labour and Child Birth, Rapid Initial
Assessment
QUICK CHECK

Ask her complaints why she has come

Ask and check records
Discuss antenatal notes with patient
If woman is very sick, talk to her companion

Initial Assessment-Look, Listen, Feel

Symptoms (Look, Listen) Vital Signs (Look, Listen, Feel)

Is the woman
• In severe pain • Looking very ill/distressed/pale • Consciousness • Anaemia • Lung auscultation
• In labour • Unconscious • Pulse, BP • Jaundice • Heart sounds
• In imminent delivery • Convulsing • Respiratory rate • Cyanosis • Do obstetric exam
• Bleeding vaginally • In respiratory distress • Temperature • Edema - Abdominal
• Dehydration - Vaginal

Classify and Categorize

1. Emergency care Call for help 2. Labour management 3. Routine Care Keep her in waiting area
Reassure the woman & her companion Transfer her to labour Explain
Start ABCD management accordingly ward Give advice and care

Emergency Care (Unconscious patient) ABCD approach

(A&B) AIRWAY AND BREATHING • If no breathing (C) CIRCULATION (D) LEVEL OF

• Shake the patient and shout - Ventilate with bag & mask Assess circulation by CONSCIOUSNESS
for help - Ask for help 1. Pulse -weak and rapid A Alert
• Turn the patient on her back • If difficulty in breathing 2. Skin temperature-cold/ V not alert but responds to
• Advanced preg-Left lateral tilt - Propped up moist vocal command
• Assess breathing for 10 secs - Oxygen inhalation 3. Pallor P responding to pain
Look-Chest movement - Auscultate lung base and 4. BP- Low U unresponsive
Listen-Breath sounds heart sound 5. Urine output/catheter
Feel-Movement of air Suspect
• Open the airway-Perform head
tilt, Chin lift, Jaw thrust a. Eclampsia
• Remove any obstruction b. APH
• Clear secretions c. Heart failure
d. Diabetes
(Hypo/ Hyperglycemic shock)
e. Hepatic encephalopathy
f. Psychiatric disorders

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3.3: Normal Labour and Child Birth

Flow chart

Diagnosis of Labour

• Diagnosis and confirmation of labour

• Diagnosis of stages and phases of labour
• Assessment of presentation, position,
engagement and descent of foetus

History taking Examination Manage accordingly

• Ask and check current and General
previous records Abdominal and
PV examination

A. Diagnosis of Stages and Phases of Labour

Symptoms and signs Stage Phase Management

• Cervix not dilated False labour/not in • Observe/discharge with advice

Labour • Treatment of pain

• Cervical dilatation <5 cm First Stage Latent • Give supportive care & assurance
• Weak contractions<3/10 min, persists< 20 sec • Monitor and record in record sheet

• Cervical dilatation > 5 cm First Stage Active • Give supportive care & assurance
• Strong contractions > 3/10 min, persists 20-30 • Start plotting partograph
sec
• Rate of dilatation> 1 cm/hour
• Engagement & descent of fetal head

• Cervix fully dilated 10 cm Second Stage Early • Close monitoring

• Fetal descent continues Non-Expulsive • Continue supportive care
• No urge to push • Record in record sheet
• Prepare for delivery

• Cervix fully dilated 10 cm Second stage Late • Close monitoring

• Presenting part reaches pelvic floor Expulsive phase • Take the patient to labour table
• Urge to push • Records in record sheet
• Prepare for delivery

• Perineal bulging, peeping of head Imminent delivery • Prepare for delivery

• Crowning • Conduct delivery
• Anal gapping

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 Normal Labour and Childbirth
Protocol for Diagnosis of Labour (History and Examination)

Diagnosis of Labour • Diagnosis and confirmation of Labour • Assessment of presentation, position, engagement and
Includes • Diagnosis of stage and phase of descent of foetus
Labour

Diagnosis 1. Painful Intermittent uterine 2. Progressive dilatation and 3. May be associated with show
Symptoms& Signs contraction effacement of cervix or watery discharge

A History taking of the woman in labour B Examination of woman in labour C Vaginal Examination Perform Vaginal
Ask, check record (General & Abdominal) of Women in labour Examination
• Greetings Look, Listen, Feel Ask, Check Record 1. Position the woman with
• Duration of labour pain • Observe appearance • Explain the legs flexed and apart
• Frequency and severity of pain - Coping well/distressed/ reason for 2. Wash hands with soap
• Movement of baby pushing examination before and after
• Ruptured membrane for how many • Check vital signs • Ensure informed 3. Put on sterile gloves
hours - Pulse consent, privacy, 4. Use chlorhexidine
• Bleeding P/V and amount - Respiration dignity & comfort cream
• Associated complaints - BP of woman 5. Perform gentle vaginal
- Headache - Pallor • Explain the examination &assess
- Fever - Edema findings to pelvis
- blurring of vision - Dehydration women & birth (do not start during a
- Vomiting - Temperature companion contraction)
- Breathing difficulties, voiding - Jaundice Look at the vulva for Determine
difficulties - Heart and lungs a) Vaginal bleeding a) Effacement of cervix
• Check LMP & EDD - Urine output b) Leaking amniotic b) Cervical dilatation in
• Determine preterm (less than 37 • Check Abdomen fluid: clear/ centimeters
weeks) term, postdated (beyond EDD) • Previous scar (if any) meconium c) Presenting part
Check previous pregnancy records • Fullness of bladder stained/foul head/breech/
• No of deliveries/abortion • Contour smelling shoulder
• Mode of deliveries: NVD, Vacuum, • Contractions-number/10min, c) Bulging perineum d) Station of head
Forceps, C/S duration, relaxation between d) Any visible fetal e) Membrane intact or
• Complications: PE, Eclampsia, PPH, contractions parts ruptured
Retained placenta, 3rd degree perineal • No of Fetus (Single/Multiple) f) If membrane is
tear etc. • Amount of liquor ruptured look for
• Outcome of baby • Fetal presentation-cephalic, color of the liquor
• LB/SB/IUD/LBW/prematurity breech transverse g) if cord prolapse-
Check current pregnancy records • Fetal movements follow guideline for
• ANC records • FHS – rate, rhythm cord prolapse
• Tetanus immunization status
• Review the birth plan
Investigations
• CBC
• Blood group ABO &Rh typing If bleeding at any time after 7 months of
• VDRL pregnancy- suspect placenta previa
• HBs Ag DO NOT perform vaginal examination
• S, TSH
• Blood sugar- 2hrs after 75gm of
glucose
• Urine R/M/E
• USG of pregnancy profile

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3.4: Normal Labour and Childbirth Management

A. Management of 1st Stage

I. Supportive care during labour and Childbirth

1 Communication 2 Birthing Companion

• Assure, praise, encourage • Encourage support from chosen • Help her to walk, breath and relax
• Maintain a calm & confident approach companion throughout the • Massage back
• Ask her permission before any procedure labour • Encourage her to drink and go to the
• Explain all procedures • Teach the companion toilet
• Inform all findings and progress • Always be with the woman • Show the woman & companions how
• Ensure and maintain privacy, respect and • Encourage and praise her to ask for help
dignity
• Involve the woman in any handover of care

3 Mobility 4 Eating/drinking 5 Urination and Bowel Care 6 Breathing technique

• Encourage to walk • Encourage to eat soft • Encourage the woman to - Teach her to notice normal
around and carbohydrate rich food- empty bladder at least 2 breathing
• Support woman’s biscuits, breads hourly - Take deep breath
choice of position in • Nutritious liquid drinks • If rectum is loaded give slowly and relax during
each stage and water glycerine suppository contraction (puff out)
• Do not give enema

7 Pain relief 8 Cleanliness 9 Transfer of Care/Referral

Support the woman to cope with pain in labour • Encourage woman to take • Explain the woman & her companion
• Walking and mobility bath and clean perineum about the reason for transfer
• Change in position with soap • Address any concern
• Breathing technique • Wash hands with soap • Ensure that her wishes are respected
• Warm shower before or after exam • Ensure that informed consent obtained
• Back Massage • Use sterile gloves for P/V • When arranging the referral- the
• If pain is constant and woman is in distress or exam caregiver should alert the relevant
anxious, find out the cause • Maintain the 5 cleans of health care professionals about
Inhalation analgesia- labour and birthing area referral.(mobile phone)
Entonox: 50:50 mixture of oxygen & nitrous oxide • Clean up spills
If needed Inj. Pethidine 1 mg/kg, no more than 100 • Routine hygiene measure
mg IM taken by stuff.
• with antiemetic I/M when cervix is 5 cm dilated
• keep antidote Inj. Naloxone ready
Do not give pethidine if delivery is anticipated within
1-3 hours 5 clean:
Regional analgesia-Epidural Clean hands
• Require obstetric setting/intensive level of
monitoring, presence of Anesthetist. Clean delivery surface
Clean blade for cutting cord
Clean cord tie
Clean cord (stump care-7.1%
chlorhexidine)

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II. Management of First Stage of Labour
a. Latent Phase

Diagnosis
Symptoms/Sign

• Intermittent lower abdominal pain

• Intermittent uterine contractions <3
contractions/10 min persist <20 sec
• Show
• Cervical dilatation<5 cm

General Management Specific Management

a. Provide assurance and supportive care • After 8 hours if

b. Monitor hourly for Emergency sign no increase in contraction
• Mood and behavior membranes intact
• Frequency & duration of contraction no progress in cervical dilatation
• Foetal heart rate Discharge the women
• Assess progress of labour and cervical dilatation • Advice to return
every 4 hourly i. if pain increases
• Record time of rupture membrane and color of liquor ii. membrane ruptures
• Record findings in labour in record sheet iii. vaginal bleeding
• Keep her under observation if
Contractions stronger and more frequent
but membranes intact-Assess progress of labour
• if no progress in cervical dilatation
o Consult with senior
o ARM may be done
o Continue close monitoring

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II. Management of First Stage of Labour
b. Active Phase

Diagnosis
Symptoms/Sign

• Intermittent lower abdominal pain

• Intermittent uterine contractions; 3
contractions/10 min, persists 20-40 sec
• Show
• Rupture of membrane
• Cervical dilatation>5 cm
• Progressive descent of presenting part

General Management Specific Management

a. Provide assurance and supportive care e. If cervical dilatation lies on or to the left of alert line
b. Monitor every 30 min for- - Continue monitoring and provide supportive care until
i. Emergency sign cervix is fully dilated

ii. Maternal Pulse f. If cervical dilatation lies to the right of alert line

iii. Frequency & duration of contraction - Reassess women

iv. FHR Intermittent auscultation of Foetal heart rate - Maintain supportive care

c. Monitor every 4 hourly-Maternal pulse, BP, - Empty bladder

temperature, cervical dilatation, descent of head, color of - Adequate hydration
liquor. - Encourage walking
d. Record finding in partograph - Monitor more frequently ½ hourly
If FHR >160 b/min (Ref: ACOG, NICE, FIGO) - if weak contractions do augmentation by oxytocin or
< 110 b/min: Then carry out continuous ARM
cardiotocography (CTG) if available • If facility for LUCS not available-Refer
If CTG not available auscultation FHR every 5 mins for g. If cervical dilatation passes to the right of action line
½ hrs, if persisting tachycardia or bradycardia follow - reassess
guideline for Fetal distress.
• Call senior or refer
Continuous monitoring by CTG (if available) • Supportive therapy & assess if progress with
Suspected chorioamnionitis/sepsis observation established & dilatation could be
anticipated at 1 cm or more
Fever 380C
• If facility for LUCS not available-refer
Severe Hypertension
• Do augmentation if needed by oxytocin or ARM
Delay in 1st stage
• If no progress deliver by caesarean section
Oxytocin use
Any complicated pregnancy

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B. Management of 2nd Stage

Diagnosis
Symptoms/Sign

Cervix fully dilated

Foetal descent continue

General Management Specific Management

• Mood and behavior • Ensure all delivery equipment and supplies are ready
• Provide supportive care, praise and assure the • Ensure empty bladder
women • Assist in comfortable position,
• Never leave the women alone provide emotional and physical support
• Monitor every 5 minutes • Allow her to push with contraction
o Frequency, duration and intensity of • When perineum is bulging and head is visible - wash
contraction hands and put on sterile gloves
o FHR • Ensure controlled delivery of the head in between
• Perineum thinning and bulging contraction

• Peeping and crowning of the Foetal head • Feel gently for cord around baby’s neck

• Record all in record sheet • Clean face and mouth

• Await spontaneous rotation of shoulder
• Place a hand on each side of baby’s head, slightly
depressed the head towards the perineum to deliver
the anterior shoulder and then lift the baby’s head up to
deliver the posterior shoulder
• Place the baby on mothers abdomen
• Thoroughly dry the baby, change wet cloth
• Note baby’s breathing, crying while drying, resuscitation
if no crying
• Manage 3rd stage
• Clamp and cut the cord within 1to3 minutes
Place baby on mothers chest, cover the baby including
head & - encourage initiation of breastfeeding

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C. Management of 3rd Stage

Diagnosis
Symptoms/Sign

The baby is just delivered

Placenta is inside the uterus

General Management Specific Management

Delivery of the placenta (AMTSL) Controlled Cord Traction

• Palpate the mothers abdomen to exclude 2nd baby • Hold the clamped cord by right hand
(twin) • At the same time place side of one hand usually left
• Give 10 IU oxytocin IM within one minute of delivery above symphysis pubis with palm facing towards
• Wait 2-3 minutes for strong uterine contraction and the mothers umbilicus. This applies counter traction
deliver placenta by controlled cord traction to the uterus during controlled cord traction. Apply
• Massage the uterus steady sustained down ward traction on cord
• Feel if uterus is well contracted • If placenta does not descend during 30-40 seconds
• Give supportive care of controlled cord traction wait until the uterus is
well contracted again then repeat controlled cord
traction with counter traction
• As the placenta is coming out, catch in both hands
to prevent tearing of the membrane
• If the membrane do not slip out spontaneously
gently twist them into a rope and move out
• Massages the uterus after delivery of placenta
• Check the placenta and membranes for
completeness
• Check the uterus is well contracted and repeat
check every 5 minutes
• Examine perineum, lower vagina and vulva for
tears
• Estimate and record blood loss in 3rd stage of
labour
• Clean perineum, place sanitary pad or folded clean
cloth
D. 4th Stage of Labour-Monitoring
Monitor Mother
• Every 15 minutes for First 24 hours
• Feel and ensure uterus is hard
• Assess vaginal bleeding, episiotomy, local tears
• Monitor pulse, BP
• Record findings and duration of 3rd stage
• Provide supportive care
Monitor Baby
Every 15 minutes
• Breathing: listen grunting, look for chest in-drawing
and fast breathing
• Warmth: check to see if feet are cold to touch
• Umbilical stump: look for bleeding

References:
1. Emergency Obstetric Care. Quick Reference Guide for Front line Provider Maternal & Neonatal Health JHPIEGO pdf.usaid.govt/pdf-docs/
PNACY 580 pdf
2. Guidelines on 8 key evidence based practices on labour. www.commonhealth.in/pdf/8.pdf
3. WHO recommendations Intrapartum care for a positive childbirth experience 2018 ISBN 978-92-4-155021-5

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3.5: Protocol for Using the PARTOGRAPH

The WHO partograph has been modified to make it simpler and Hours: Refers to the time elapsed since onset of active
easier to use. The latent phase has been removed and plotting on phase of labour, starting time is “0” hours.
the partograph begins in the active phase when the cervix is 5 cm Time: Record actual time.
dilated. A sample partograph is included. Record the following on the
partograph: Contractions: Chart every ½ hour; palpate the number of
contractions in 10 minutes and their duration in seconds.
Patient information: Fill out name, gravida, para, hospital number Record on the right side of the time line and fill up two
date and time of admission and time of ruptured membranes. consecutive boxes of two lines.
Fetal heart rate: Record every half hour. • Less than 20 seconds:
Amniotic fluid: Record the color of amniotic fluid at every vaginal • Between 20 and 40 seconds:
examination:
• More than 40 seconds:
• I: membranes intact:
Oxytocin: Record the amount of oxytocin per volume IV
• C: membranes ruptured , clear fluid; fluids in drops per minute every 30 minutes when used.
• M: meconium-stained fluid; Drugs given: Record any additional drugs given.
• B: blood-stained fluid. Pulse: Record every 30 minutes and mark with a dot (.)
Moulding: Record using the following key Blood pressure: Record every 4 hours and mark with
• 1: sutures apposed: (+) arrows.

• 2: sutures overlapped but reducible; (++) Temperature: Record every 4 hours.

• 3: sutures overlapped and not reducible (+++) Protein: Perform this test at admission for all patients, but
repeat as indicated for PE/Eclampsia/renal disease
Descent assessed by abdominal palpation: Refers to the part of Volume: Record every time urine is passed, encourage to
the head (divided into 5 parts) palpable above the symphysis pubis, pass urine
recorded as a circle (O) at every examination. For example: At 0/5, Acetone: Examine only if indicated & especially in diabetes
the sinciput (S) is at the level of the symphysis pubis. & maternal distress.
Cervical dilatation: Assessed at every vaginal examination.
Marked with a cross (x) on alert line of admission. Begin plotting on
the partograph at 5 cm. Check every 4 hours.
Alert line: A line starts at 4 cm of cervical dilatation to the point of
expected full dilatation at the rate of 1 cm per hour. Start 1st plotting
on alert line.
Action line: Parallel and 4 hours to the right of the alert line.

To be recorded on the time line: Cervical dilatation, descent of Foetal head, FHS, pulse, moulding, hours, time, contractions,
oxytocin, drugs/I. V fluid given, blood pressure, temperature and urine (protein, acetone and volume)

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4: INDUCTION OF LABOUR (IOL)

DEFINITION
Induction of labour is the initiation of uterine contractions after the period of viability who is not in labour with an aim to
achieve a vaginal birth within 24 to 48 hours.
General principles related to the practice.
• Should be performed with caution, since this procedure carries risk of uterine hyper stimulation and rupture and fetal
distress
• Facilities should be available for assessing maternal and fetal well-being.
• Women should never be left unattended.
• Whenever possible, induction of labour should be carried out in facilities where cesarean section can be performed.

Information and Decision making

 Woman should be well informed that most women go into labour spontaneously by 42 weeks.
 At 38 week’s visit, inform about risk of continuation of pregnancy >42 weeks and their options.
 Risk and benefits of induction of labour in specific circumstances and the proposed induction methods

The information should cover

 Membrane sweeping
 Induction of Labour at 41wks
 Expectant management (advantage & disadvantage)
 Reason for induction being offered
 When, where and how induction could be carried out
 Arrangement for support and pain relief
 Alternative option of women to choose not to have induced
 Induction may not be successful in that case cesarean section is alternative option

Modified Bishop Score

Modified Bishop Scoring System
Factor Score
A. Cervix 0 1 2 3
Dilatation (cm) 0 (Closed) 1-2 3-4 5-6
Effacement, % 0-30 40-50 60-70 80
Length (cm) >3 1-3 <1
Consistency Firm Medium Soft
Position Posterior Mid Anterior
B. Head Station -3 or above -2 -1 or 0 +1, +2

Total score: 13, Favorable score: 6-13, Unfavorable score: 0-5

Pre IOL assessment

 Review history
 Confirm gestational age by LMP & early USG
 Baseline observations-vital signs, Pulse, B.P, Heart, Lungs
 Abdominal palpation (presentation, attitude, FHR, lie, engagement)
 CTG: if available, consult Obstetrician if abnormal

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 Vaginal examination:
• Assess MBS (Modified Bishops Scoring)
• Membrane status (intact or ruptured)

Booking for IOL

Prior to booking for IOL the Medical Officer will
1. Document the indication for induction
2. Find out if there are any contraindications for IOL and discuss with the lead obstetrician
3. Confirm gestational age
4. Assess fetal wellbeing-Clinical/CTG & USG
5. Obtain written informed consent which includes reason for IOL, choice of IOL method(s)to be used, potential risks of
IOL and consequences for accepting or refusing a recommendation of IOL

Day of admission
Prior to commencement of IOL the Medical Officer/Midwife will:
1. Ensure that an informed consent has been obtained prior to admission
2. Review the indication for IOL
3. Ensure that there are no contraindications for IOL
4. Confirm gestational age
5. Assess fetal well being
6. Discuss the process for IOL
7. Assess fetal lie/presentation/position
8. Assess membrane status (intact/ruptured)
9. Assess Bishop score on admission & documentation.

Methods of Induction of Labour

1. Mechanical
¡ Membrane sweeping
¡ Foley’s Catheter
2. Medical
¡ Prostaglandins
¡ Dinoprostone (E2)
¡ Misoprostol (E1)
¡ Oxytocin
3. Surgical
¡ ARM
4. Combined

Membrane Sweeping
 Routine sweeping (stripping) of membranes promotes the onset of labour and decreases induction rates.
 This technique results in an increase of local production of prostaglandins.

Sweeping membrane is recommended for reducing formal induction of labor. There is evidence that routine sweeping of
the membranes promotes the onset of labour& decreases the induction rates. When the cervix is closed, a massage of
cervical surface with index finger & middle finger for 15-30 seconds gives the same result.

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 PROSTAGLANDINS
MISOPROSTOL
A synthetics PGE1 analogue
1. Oral
2. Sublingual
3. Vaginal
Dosage
1. 25 mg orally 2 hourly (maximum 4 doses)
2. 25 mg vaginally in posterior fornix 6 hourly (maximum 4 doses)
If no effect after 2 doses increase dose of 50 mg every 6 hourly
Caution
Choose only one route
Do not use misoprostol in grand multi/scarred uterus (H/O C/S, H/O Myomectomy)
Notes:
Do not exceed 4 doses in 24 hours
Do not use > 50 mg at a time. (Assess uterine contraction before giving each dose).
Adverse Effects
 Serious adverse events with the use of misoprostol are similar to those of other PG, e.g.
Uterine tachysystole with its potential fetal and maternal effects, meconium staining of liquor.
It is a potent uterotonic and should not be used in women with a previous CS.
Life-threatening uterine rupture that has been reported anecdotally in women with a previous CS.

Prostaglandin E2 (Dinoprostone)
Prostaglandins E2, (dinoprostone) acts on the cervix by dissolving collagen structural network of the cervix.
Preparation
1. Intra cervical 0.5 mg/500 mg gel (Cerviprime gel) (available in Bangladesh)
2. 10 mg pessary (Cervidil)
3. Intra vaginal tablet 1 mg/2mg (Prostin)

Dosage
0.5mg Endocervical gel vaginally 6 hourly (maximum 4 doses for 24 hours)

Post dose care

 After insertion advise woman to-
¡ Remain recumbent for 30 minutes
¡ Inform staff as soon as contractions commence
 Observe Pulse, BP, FHR, uterine activity, P/V bleeding/discharge hourly for 4 hours
 CTG for minimum of 30 minutes (if available)
 If observations normal, no contractions and not otherwise indicated, ongoing care as for latent first stage of labour
 Continuous CTG when in active labour or when contractions are ≥ 3 in 10 minutes. If not possible FHR auscultation
immediately after a contraction. Fetal distress if rate <100 b/min

Cautions
Choose only one route (oral/vaginal)
Before each insertion of Prostaglandin (Dinoprostone) check uterine contraction and cervical dilatation
Do not use Dinoprostone in grand multipara and in scarred uterus

Discontinue Prostaglandin if
Membrane ruptures
Cervical ripening achieved
Good labour pain established
Maximum dose is reached
Foetal distress/uterine hyper stimulation occur
Begin oxytocin infusion if needed after 6 hours of using last dose of Misoprostol/Dinoprostone

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 OXYTOCIN
 Review the prerequisites carefully
 Give effective dose of oxytocin but the response varies greatly between women
¡ Rule - Always start with low dose infusion
¡ Gradually increase rate of infusion until good uterine contraction is established
¡ Then maintain the rate until delivery
 Never leave the woman alone receiving oxytocin
 Carefully monitor maternal pulse, BP, uterine contractions and FHR every 1/2 hourly in active phase
 Criteria for good labour pattern, - 3 contractions / 10 minutes & each lasting 40 seconds
 Maintain cold chain system. Keep it in freeze.

DOSE OF OXYTOCIN (Oxytocin Protocol)

 Starting dose: infuse oxytocin 2.5 units in 500 ml of lactoride or N/S at 10 drops / min (2.5 miu/min)(i.e. 0.5 ml/min or
10d/min)
 Increase the infusion rate by 10 drops / min every 30 min until good contraction pattern is established
 Maintain this rate until delivery
If good contraction pattern not established with infusion rate of 60 drops / min
-Increase oxytocin concentration to 5 units in 500 ml of Lactoride/ NS and start from 30 dpm (15 miu/min) increase the
rate by 10 dpm every 30 min, until good contraction is established or maximum rate of 60 dpm

If labour still not established

 In multigravida and woman with previous C/S consider this as failed induction and deliver by C/S
 In primigravida - Use oxytocin 10 units in 500 ml of lactoride/NS and start with 30 dpm and then increases the rate by
10 dpm every 30 min until good contractions established or maximum rate is reached (60 dpm)
If labour not established consider failed induction -consider other method or delivery C/S
If hyper stimulation (contraction lasts > 60 secs or tachysystole (>5 contractions /10 min) occurs
¡ Stop the infusion
¡ Use tocolytics–Terbutalin 250 µgm I/V slowly over 5 min or / Salbutamol 10 mg in 1L N/S or lactoride at 10 dpm.
¡ If not available or in cardiac patients, Nifedipine 20mg/oral may be used.
¡ Monitor pulse, uterine relaxation and FHR
¡ Keep the woman in left lateral position and start oxygen inhalation
¡ Stay with women until normal uterine activity achieved.

FOLEY’S CATHETER
 Useful alternative to prostaglandin specially in multigravida patient or patient with previous C/S
 Review the prerequisites
 Exclude contraindications-P/V bleeding, Ruptured membrane, obvious cervicitis, vaginits.

Procedure
 Place the woman in dorsal position
 Introduce a sterile Sim’s speculum
 Hold the cervix with sponge holding forceps (anterior lip)
 Hold the Foley’s catheter with sterile artery forceps- away from the tip
 Do not touch the portion of Foley’s catheter which will go inside the cervix
 Gently introduce the catheter through the cervix beyond the internal OS
 Inflate the bulb with 30-50 ml of water
 Fix the catheter at the thigh with tension
 Leave the catheter until contraction starts and catheter fall off or remove it after 12 hours

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 ARM

Protocol
 Review the prerequisites
 Do not do ARM if the patient is HIV (+ve) or HBsAg (+ve)
 Position the woman in dorsal position
 Gently do PV examination and assess the cervix
 Introduce a Kocher’s artery forceps inside the vagina guiding it with the fingers to the membrane
 Place two fingers against the membrane and rupture the membrane with instrument in the other hand
 Allow the amniotic fluid to drain slowly
 Note the color of the liquor, FHR
 Give prophylactic antibiotics-Inj. Amoxycillin 500 mg 8 hourly/Cephalosporin 500 mg 6 hourly
 If good labour pain not established after 1 hour of the ARM, start oxytocin infusion

Flow Chart of Oxytocin Regime

1 bag
st

500ml 2.5 unit oxytocin in 500 ml N/S @ 10 drops/min (2.5mIU/ml)

by 10 drops every 30 min up to 60 drops until good uterine contraction

No good uterine contraction @ 60 drop/min

2nd bag

500ml 5 unit in 500 ml N/S @ 30 drops/min (15mIU/ml)

by 10 drops every 30 min

MULTI PRIMI

Failed 3rd bag

500ml 10 IU in 500 ml N/S @30drops/min

CS

by 10 drops every 30 mins

No good contractions @ 60 drops/min

Consider Failed induction

C/S

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 Flow Chart

A. PRIMI with intact Membrane

Time 0

1st Vaginal Exam

Pre IOL Assessment at 41 wks

If no contra indication

Insert Misoprostol
Record temp, pulse, BP,
Repeat CTG &P/A Exam
Vaginal Exam
After 6hrs
MBS*

>6 <6

ARM Review by senior

+ Oxytocin person

Misoprostol
2nd doses
Assessment of uterine activity hourly

Uterus Contracting Uterus not Contracting

MBS
6hours

>6 <6 MBS

After 2hrs
ARM (8 hours after first vaginal >6 <6
examination)
+Oxytocin MBS

>6 <6 ARM

ARM after 1hr Misoprostol
Prostaglandin Total
(Misoprostol) time
+Oxytocin 12hr
3rd doses
+Oxytocin VE by seniors
* MBS- Modified Bishop Score
* VE- Vaginal Examination
Vaginal
* IOL-Induction of Labor Exam

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B. MULTIPAROUS WOMAN (with previous 1 or more vaginal delivery)
40 wk onwards
Cx Sweeps for 1 or 2 occasion

Offer induction of labour at 41 wks

Time 0

Vaginal Exam

Pre-IOL Assessment

MBS

>7 <7
ARM not Possible

ARM Mechanical
+ Oxytocin with Foley’s Catheter overnight

l Unable to introduce l Foley’s Catheter falls off l Balloon deflated after 12 hour
Foley’s Catheter

Prostaglandin ARM ARM ARM not possible

Misoprostol +Oxytocin +Oxytocin
(If possible) Give prostaglandin/
Misoprostol

Review by Senior Obstetrician

C. PRIMI Rupture Membrane
Time 0

1st Vaginal Exam

MBS
>7 favorable cx <7
Unfavorable cx
Oxytocin
Misoprostol
After 6 hour
2nd Vaginal Exam
MBS

>7 <7
Oxytocin Misoprostol

Assessment of uterine activity hourly

Uterine Activity No Uterine activity

6 hrs
Vaginal assessment Start
Oxytocin infusion
If necessary
Oxytocin infusion

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D. MULTIPAROUS woman with Previous 1 C/S

Pre-IOL assessment

Await spontaneous onset of labour

Preferably up to 41 wks

One/more cervical
sweeps from 40 wks onwards

MBS

>7 woman declines

ARM Elective C/S

+Oxytocin

MBS<7

Mechanical Induction
with Foley’s Catheter

Balloon falls out Balloon removed

after 12 hrs

ARM ARM not possible

+Oxytocin

C/S

Note: Give antibiotic after cervical sweeping

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E. IUD

Pre-IOL assessment

Time 0

P/V

MBS

>7 <7

Oxytocin
Prostaglandins
Misoprostol

Reassess uterine activity hourly

Contracting Not Contracting

Send to labour room MBS

>7 <7

Augmentation with
Oxytocin if needed Oxytocin Foley’s Catheter

Balloon falls remove balloon

After 12 hours

Oxytocin
Oxytocin

Caution
Surgical induction is contraindicated in IUD

32 STANDARD CLINICAL MANAGEMENT PROTOCOLS AND FLOWCHARTS ON

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F. IUD with previous C/S

Time 0
Pre-IOL assessment

P/V

MBS

>7 <7

Oxytocin Foley’s Catheter

Balloon fall off Remove Balloon after 24hrs

Oxytocin
MBS

>7 <7

Oxytocin Reinsert Foley’s Catheter 2nd time

Reassess

Caution
• Prostaglandin is contra indicated in previous C/S
• ARM is contraindicated in previous C/S

Reference:
1. ACOG Practice Bulletin No-107
2. WHO & FIGO recommended regimen 2017
3. A Clinical Guideline for the Induction of Labour (IOL) Process
Norfolk and Norwich University Hospital (NHS), August 2016 to review 2019
4. Integrated Management of Pregnancy and Childbirth (IMPAC)
5. Queensland Clinical Guidelines
6. SOGC Clinical Practice Guideline

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5: Unsatisfactory Progress of Labour

Unsatisfactory progress of labour may be due to delay in 1st stage or 2nd stage of labour.

Contributing factors are:

1. Psyche (Lack of antenatal education, support in labour)

2. Passenger (Big baby, mal presentation and malposition)
3. Powers (inefficient uterine contraction in active phase of labour)
4. Passage (pelvic abnormalities, Cephalo-pelvic disproportion)

Delay in 1st stage of Labour

Prolonged latent phase:
The latent phase is longer than 12 hours in primipara or longer than 8 hours in multipara.
Prolonged active phase:
 When cervical dilatation is to the right of the alert line.
 Cervical dilatation of less than 2cm in 4 hrs for first and subsequent labours
 Delay in descent and rotation of fetal head
 Changes in strength, duration and frequency of uterine contraction

Delay in 2nd stage of Labour

Prolonged 2nd stage of Labour

• Nulliparous:
No progress in descent or rotation for > 3 hours without an epidural, and > 4 hours with an epidural

• Parous:
No progress in descent or rotation for > 2 hours without an epidural, or > 3 hours with an epidural.

Secondary arrest
In 1st stage failure of cervical dilatation & descent of presenting part in presence of good contraction.

Obstructed labour

Delay in descent of presenting part in spite of good uterine contraction.

Note: A minimum cervical dilatation rate of 1cm/ hr. throughout active stage of labour is unrealistically fast for some
women and is therefore not recommended for identification of normal labour progression.

A slower than 1-cm/ hr. cervical dilatation rate alone should not be an indication for obstetric intervention.

34 STANDARD CLINICAL MANAGEMENT PROTOCOLS AND FLOWCHARTS ON

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Flow Chart
Unsatisfactory Progress of Labour
Management
1st Stage of labour

Prolonged Latent Phase Prolonged Active Phase Secondary Arrest

1. Assurance Exclude any sign of Failure of Cc dilatation
Woman may be encouraged to obstruction or CPD or fetal & descent of presenting
stay at home distress part in presence of good
If membrane intact- do ARM uterine contraction

2. Presence of a support person Ô Obstructed labour

• Secondary arrest of
3. Encourage ambulation and Assess uterine contraction
cervical dilatation &
adequate hydration
Ô descent of presenting
part
4. If patient is at home she may be If contraction < 3 /10min • Large caput
referred to Consultant led unit &<40sec duration, it indicates • Third degree
(CLU),when moulding
• Cervix poorly applied
• Pain intensity increases
• membrane ruptures
Ô to the presenting part
• Less fetal movement • Oedematous cervix,
Inadequate uterine contraction ballooning of lower
uterine segment
At CLU
• Assurance Ô • Formation of
retraction band,
• Augmentation of labour with maternal &Foetal
Augment by oxytocin
ARM and Oxytocin distress
• Plot Partograph
• Give antibiotic
Ô Management
Resuscitation as
Amoxicillin/Cephalosporine
Oxytocin infusion drop increment required
every 30 min by 10 drops until
adequate uterine contraction Ô
Followed by
If the woman has not entered
the active phase after 8 hours of Ô Ô
oxytocin infusion C/S
Assess after 2 hours
Ô Ô
Do C/S

If no progress If progress

Ô Ô
CS Continue
and assess 2
hourly

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 Management
2nd Stage of labour

Ô
Ô Ô
In Nulliparous woman In Multiparous woman

Ô Ô
If after 1 hour of active second stage After ½ hour of active second stage
progress is inadequate

Ô Ô
Delay is suspected Progress is inadequate

Ô Ô
ARM should be done for intact Delay is suspected
membrane
Ô

ARM should be done for intact

Good progress If Foetal distress membrane
Conduct VD Consider (Follow as like Nulliparous woman)
Ventouse/
Forceps

Oxytocin if inadequate
Contraction ( exclude

Ô
Obstruction&
malpresentation

No descent after augmentation

Ô
C/S

Note:
• Birth expected to take place in 3 hours of start of active second stage in nulliparous & in 2 hours in multiparous woman.
• The use of oxytocin is not recommended in parous women (Ref: NICE Guideline)
• Do not routinely use oxytocin in the second stage of labour for women with regional anesthesia
• If women is excessively distressed , give support and sensitive encouragement
• Talk with woman & her birth companions about why birth needs to be expedited

Reference:
1. Clinical guidelines of Management of normal labour and prolonged labour in low risk patients, Mid Essex Hospital Services (NHS) , 2015
2. WHO recommendations Intrapartum care for a positive childbirth experience WHO,ISBN 978-92-4-155021-5,2018

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6: Protocol for Foetal Distress

Definition: Foetal distress refer to compromise of foetus due to inadequate oxygen or nutrient supply. This can occur due
to maternal, fetal or placental factors.
Cause:
Main cause of Foetal distress is uteroplacental insufficiency

Risk Factors: Symptoms/ Signs

1. Oligohydramnios, polyhydramnios  Decreased Foetal movement
2. Multiple pregnancy  Thick meconium stained liquor
3. Rh isoimmunisation  Abnormal Foetal heart rate (less than 100 is
4. Hypertension/Pre-eclampsia bradycardia or more than 160 beats per minute is
Foetal tachycardia).
5. Diabetes Mellitus/GDM
 Abnormal CTG ( Non reassuring )
6. Fetal growth restriction
7. Less Foetal movement General Management
8. H/O stillbirth • Propped up position or place mother on left lateral
9. Postdated pregnancy position
• Stop oxytocin if it is being administered.
• Give oxygen by mask

Foetal heart rate

• A normal Foetal heart rate may slow during a contraction but recovers to normal as the uterus relaxes.
• A very slow Foetal heart rate in the absence of contractions or persisting after contractions is suggestive of Foetal
distress
• A rapid Foetal heart rate may be a response to maternal fever, hypertension, chorioamnionitis or by drugs causing
maternal tachycardia (e.g. tocolytic drugs).
• In the absence of maternal tachycardia, Foetal tachycardia should be considered as a sign of Foetal distress.
• If a maternal cause is identified (e.g. maternal fever, drugs), initiate appropriate management.
• If a maternal cause is not identified and the Foetal heart rate remains abnormal throughout at least three contractions,
perform a vaginal examination to check for explanatory signs of distress:
¡ If there is bleeding with intermittent or constant pain, suspect abruption placentae
¡ If there are signs of infection (fever, foul-smelling vaginal discharge) give antibiotics as for chorioamnionitis
¡ If the cord is below the presenting part or in the vagina, manage as prolapsed cord
• If Foetal heart rate abnormalities persist or there are additional signs of distress (thick meconium stained fluid), plan for
delivery.
¡ If the cervix is fully dilated and the Foetal head is not more than 1/5 above the symphysis pubis or head is at +2
station, deliver by vacuum extraction or forceps.
¡ If the cervix is not fully dilated or the Foetal head is more than 1/5 above the symphysis pubis or head is 0 or
above stations, deliver by caesarean section.

Reference:
1. Foetal distress –signs of Foetal distress and treatment
https//patient.info>doctor> fetal distress
2. Intrapartum Foetal distress – RCOG. http;//wwwrcog.org,uk

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 Flowchart for Management of Foetal Distress

Foetal Distress • Persistent abnormal FHR (< 100 or > 160 beats /min)
• Thick meconium stained liquor
• Abnormal CTG

Ô
General Management • Position : Propped up /left lateral
• Assurance
• Stop Oxytocin
• Give O2

Specific Management of Foetal Distress Ô

Find the causes Exclude Maternal causes
 Cord presentation/prolapse  Fever
 Abruptio placenta  Dehydration
 Chorioamnionitis  Drugs
 Prolonged/obstructed labour  Hypertension
 Haemorrhage
Treat accordingly

Ô
 Look for FHR in absence of contraction or whether abnormal FHR persists after contraction or repeated
during contraction
 Look for presence of additional signs of distress
 Thick meconium stained liquor
 Abnormal CTG

Ô
Plan for Delivery

Ô
First Stage LUCS
Second Stage
 Cervix fully dilated and station +2 or more : Deliver by vacuum/forceps
 Cervix fully dilated but station 0 or above : Deliver by Caesarean Session

Foot Note:
• Meconium staining amniotic fluid is seen frequently as the fetus matures and by itself is not an indicator of Foetal distress. A slight degree
of meconium with Foetal heart rate abnormalities is a warning of the need for vigilance.
• Thick meconium suggests passage of meconium in amniotic fluid and may indicate the need for expedited delivery and management of
neonatal airway at birth to prevent meconium aspiration.
• In breech presentation, meconium is passed in labour because of compression of the Foetal abdomen. This is not a sign of Foetal distress
unless it occurs in early labor

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7: Clinical Guideline for the Management of
Shoulder Dystocia (SD)

Definition: Shoulder dystocia is an acute obstetrical emergency where the Foetal head has been delivered but the
shoulders are stuck and cannot be delivered.

Signs of recognizing shoulder dystocia:

• Foetal head has been delivered but shoulders are stucked and cannot be delivered.
• Foetal head remains tightly applied to the vulva
• The chin retracts and depresses the perineum
• Traction on the head fails to deliver the shoulder either the anterior or the posterior shoulder which is caught
behind the pubic symphysis or sacral promontory.

Risk factors
Antepartum
1. Excessive weight gain (>35 lb/15.9 kg) during pregnancy.
2. Maternal obesity (BMI > 30 kg/m2)
3. Post term pregnancy
4. Fetal macrosomia (large body compared to head)
5. Diabetic mother
6. Multiparity

Intrapartum
1. Operative vaginal delivery (Vacuum, forceps)
2. Prolonged second stage of labour

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 Summary of management of Shoulder Dystocia (SD)
H Help
E Edge& Episiotomy
L Legs (Mc. Robert’s maneuver)
P Pressure (Suprapubic pressure)
E Enter (RUBIN II & Wood Screw maneuver)
Management R Remove (Delivery of posterior arm)
R Roll (All 4)

1. Call for help.

2. Move the woman to lie with her buttocks over the edge of table.
3. Make adequate episiotomy to reduce soft tissue obstruction and to allow space for internal maneuvers.
• Apply form, continuous traction downwards on fetal head to move anterior shoulder under the symphysis pubis
• Avoid excessive traction on the head as this may result in brachial plexus injury

1. Mc Robert manoeuvre
• Mc Robert position-woman on her back, ask her to flex both thighs, bringing her knees as far up as possible
towards her chest, abduct and rotate legs outwards
• Do not apply fundal pressure. This will further impact the shoulder.

1. If the shoulder still not delivered

RUBIN-1 (Suprapubic pressure)-is rotation of anterior shoulder towards fetal chest under pubic symphysis. This reduces
bisacromial diameter.
i. Have an assistant at the mothers side, place their hands on the suprapubic region of mothers abdomen
ii. Position is similar to that of CPR with assistant above the woman
iii. With the heel of the hand (or fist) and arms straight, apply moderate pressure obliquely (downward and laterally) to
fetal anterior shoulder.
iv. Use right hand for performing this maneuver if the fetus is facing mothers right side and vice versa.
v. If continuous pressure does not dislodge the shoulder use a rocking motion (compression/relaxation)

2. RUBIN II (if above measures fail)

Insert one hand vaginally behind the posterior aspect of anterior shoulder of foetus and rotating the shoulder towards
chest shifting it from midline to oblique diameter. As a result shoulder girdle is adducted and diameter is reduced

3. Wood’s screw maneuver-which leads turning the anterior shoulder to the posterior and vice versa.

4. Jacquemier’s maneuver (Delivery of posterior arm)-in which the fore arm and hands are identified in the birth canal
and gently pulled.

5. All four position :

Placing the woman in the all fours position i.e hands and knees (Rolling of the patient on her hand and feel), may
dislodge the anterior shoulder and facilitate delivery.
The all fours position offers evenly distributed weights on all four limbs and maximizes the pelvic diameters, when
adequate room is available along the curve of the sacrum to allow a hand to be inserted up to the Foetal waist to deliver
the posterior shoulder or arm.

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Flow chart
Action
Call for help

Move the women to lie with her buttocks at the edge of the bed

Make an adequate episiotomy

With the woman on her back, ask her or assistants to flex both thighs, abduct and rotate legs outwards bringing her
knee as far up as possible towards her chest (McRobert’s position)

Ask the assistant, apply suprapubic pressure by using the heel of the hands from above to push shoulder down under
the symphysis pubis (Do not apply fundal pressure) RUBIN-1

Apply firm, continuous traction downwards on the fetal head to deliver the anterior shoulder

If the shoulder is still not delivered: Insert an hand into the vaginal along the baby’s back and apply pressure to the
posterior aspect of anterior shoulder in the direction of the baby’s chest to rotate and decrease the Biacromial
diameter and deliver ant shoulder RUBIN-2

If above procedure failed, apply pressure to the posterior shoulder in the direction of the sternum to reduce the
diameter and deliver the posterior shoulder

Turning the anterior shoulder to the posterior and vice versa- Wood’s screw maneuver

If the shoulder still is not delivered despite the above measures, try to deliver the posterior shoulder first: Grasp the
humerus of the arm that is posterior and, keeping the arm flexed at the elbow, sweep the arm across the chest. This will
provide room for the shoulder that is anterior to move under the symphysis pubis Jacquemier’s maneuver

All four position :

Placing the woman in the all fours position i.e hands and knees(Rolling of the patient on her hand and feel), may dislodge
the anterior shoulder and facilitate delivery.

After delivery, resuscitate the baby

Perform active management of the third stage of labour to deliver the placenta

Check the birth canal for tears following childbirth and repair episiotomy

SALVAGE
1. Sling-Applying traction by hooking the axilla to extract the posterior arm
2. Cleidotomy
3. Symphisiotomy
4. Zavanielle-Push the head inside and delivery by cesarean section
Reference:
1. RCOG Green top Guideline No-42 Nov 2014 page 6-9
2. Essential Obstetric and Newborn Care, Lifesaving skills manual, RCOG in partnership with LSTM, WHO, LATH

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8: Protocol for Prolapse of Umbilical Cord

Definition: Descent of the umbilical cord through the cervix, alongside (occult) or past the presenting part (overt) in the
presence of ruptured membranes.
Risk factors for cord prolapse:
• Multiparity
• Low birth weight of fetus (<2.5 kg)
• Fetal Congenital anomalies
• Transverse, oblique, unstable lie
• Breech presentation
• Second twin
• Polyhydramnios
• Unengaged presenting part
• Low lying placenta
• ARM with high presenting part
• Stabilizing induction of labour
• Internal podalic version
General management:
• Give 02 @ 4-5 L/ min
• Cover the cord with a sterile warm normal saline soaked mob
• Feel for cord pulsation
Specific management:
A. Cord pulsating (foetus alive ) * Check FHR
* Detect Foetal lie
* Minimum handling of the cord to avoid vasospasm
1. If transverse lie and gestational age is term or near term –Emergency caesarean section or Refer immediately.
2. If transverse lie and gestational age is extreme preterm – Counsel with mother and guardian regarding chance of
viability and deliver that is safe for the mother.
3. If longitudinal lie – Diagnose stage of Labour by immediate vaginal examination
a) If the woman is in the 1st stage of labour
 Assistance should be called immediately & preparation made for immediate birth.
 Option to relieve cord compression –
- Knee chest (prayer position) position/Left lateral position (left lateral with pillow under hip)
- Inflate the bladder with 500 ml. of normal saline and clamp the Catheter.
 Use tocolytics as necessary
 Prepare for neonatal resuscitation
Perform immediate caesarean section and deflate the catheter before peritoneal incision.
b) If the woman is in the 2nd stage of labour-
 Expedite the delivery with forceps or ventouse, if presentation is vertex
 Perform breech extraction if presentation is breech.
 Prepare for neonatal resuscitation.
B. Cord not pulsating –
Check FHR
Counsel with the mother and the guardian that foetus is dead and deliver in the manner that is safe for the mother.

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 Flow chart for prolapse of umbilical cord
Umbilical cord is seen or felt in the vagina or outside the vagina following rupture of membranes

Ô
Call for help

Ô
Feel the cord

Cord pulsating (Foetus alive) * Give O2 @ 4-6 L / min. Cord not pulsating
* cover the cord with warm
Ô (Foetus dead)
Normal saline soaked mob
Check FHR Prepare for neonatal resuscitation
Ô Ô
Detect lie of the baby Deliver the baby that is safe for the mother

Longitudinal lie Transverse lie

Term Preterm Ò Counsel the mother regarding the chance of viability

Ô
Refer / caesarean section

Diagnose the stage of labour Ò 2ndstage of labour

1st stage of labour Vertex Breech Ò Breech extraction

Expedite delivery by Forceps/ventouse

Transfer to OT on urgent basis for CS in the above

Option to relieve cord compression manner & deflate catheter before peritoneal incision
Knee-elbow position/Left lateral position (preferably
with head down & pillow under the left hip) Or, Refer in the above manner
Inflation of bladder with 500 ml of normal Saline and Prepare for neonatal resuscitation
clamp
Tocolytic to reduce uterine contraction as necessary

1. Reference: Green-top Guidelines No-50, Nov 2014

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9: Protocol for Vaginal Delivery after Caesarean
Section/Scarred uterus (VBAC)

Planned VBAC
Planned VBAC (vaginal birth after caesarean) refers to any woman who has experienced a prior caesarean birth, who
plans to deliver vaginally rather than by ERCS (elective repeat caesarean section).

Problem
Increasing rate of primary cesarean section. So, repeat section has increased.

Successful / Unsuccessful
A vaginal birth (spontaneous or assisted) in a woman undergoing planned VBAC indicates a successful VBAC.
Birth by emergency caesarean section during the labour indicates an unsuccessful VBAC.

Maternal outcomes
● Uterine rupture is defined as a disruption of the uterine muscle extending to and involving the uterine serosor disruption
of the uterine muscle with extension to the bladder or broad ligament.
● Uterine dehiscence is defined as disruption of the uterine muscle with intact uterine serosa.
● Other outcomes: hysterectomy, thromboembolism, haemorrhage, transfusion requirement, viscus injury (bowel, bladder,
ureter), endometritis, maternal death.

Antenatal counseling
 Women with a prior history of one uncomplicated lower-segment transverse caesarean section, in an otherwise
uncomplicated pregnancy at term, with no contraindication to vaginal birth, should be able to discuss the option of
planned VBAC and the alternative of a repeat caesarean section (ERCS).
 The antenatal counselling of women with a prior caesarean birth should be documented in the notes.
 A final decision for mode of birth should be agreed between the woman and her obstetrician before the expected/
planned delivery date (ideally by 36 weeks of gestation).
 Women considering their options for birth after a single previous caesarean should be informed that, overall the
chances of successful planned VBAC are 72–76%.
 All women who have experienced a prior caesarean birth should be counselled about the maternal and perinatal
risks and benefits of planned VBAC and ERCS when deciding the mode of birth.
 The risks and benefits should be discussed in the context of the woman’s individual circumstances, including
 Personal motivation and preferences to achieve vaginal birth or ERCS
 Attitudes towards the risk of rare but serious adverse outcomes
 Plans for future pregnancies
 Chance of a successful VBAC (principally whether she has previously had a vaginal birth
 Review of the operative notes of the previous caesarean to identify the indication, type of uterine incision and any
perioperative complications.

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Factors associated with successful VBAC
Previous vaginal birth, particularly previous VBAC, is the single best predictor for successful VBAC

Factors for unsuccessful VBAC are:

 Induced labour
 No previous vaginal birth
 Body mass index greater than 30
 Previous caesarean section for dystocia
 VBAC at or after 41 weeks of gestation
 Birth weight greater than 4000 g
 No epidural anesthesia
 Previous preterm caesarean birth
 Cervical dilatation at admission less than 4 cm
 Less than 2 years from previous caesarean birth
 Advanced maternal age
 Non-white ethnicity
 Short stature and
 A male infant

Contraindications to VBAC
1. Women with a prior history of one classical caesarean
2. Women with a previous uterine incision other than an uncomplicated low transverse caesarean section incision
3. Previous uterine rupture
4. Uterine incision has involved the whole length of the uterine corpus
5. Two or more previous caesarean deliveries
6. Who experienced both intrapartum and postpartum fever in their prior caesarean birth are at increased risk of uterine
rupture in their subsequent planned VBAC labour

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Flowchart
Flowchart for Delivery option after Caesarean Section

Previous Caesarean Section

Ô
Ô Ô
Elective caesarean section Allow spontaneous vaginal delivery
Two or more previous CS 1 previous CS for non-recurring indication
Previous classical CS Low transverse uterine incision
Previous CS done for recurrent Vertex presentation
indication Normal size baby < 3.5 kg
Successful repair of VVF
One previous CS with any Wait for spontaneous onset of labour upto
obstetric complication especially 7 days after EDD
in malpresentation, borderline
disproportion, big baby
Ô
Trial of vaginal delivery
(in a centre where immediate caesarean section can
be carried out, if required)

Ô
Special care in labour and delivery

Ô
IV infusion
Hemoglobin status, cross matched blood available
Close monitoring of FHR, uterine contraction and
maternal pulse
Strict partogram record and management

Ô
Management

Ô Ô Ô
Normal Progress Abnormal Progress Signs of impending
rupture

Ô Ô
Aim for vaginal delivery Signs of abnormal progress
Persistent maternal
Ô pulse > 110/min
May consider Cervical dilatation Suprapubic tenderness
forceps/vacuum rate right of alert line, Excessive blood
extraction in incoordinate uterine stained PV discharge
second stage if contractions, arrest of Sign of fetal distress
prolonged descent of Foetal head

Reference: Emergency Caesarean Section

1. Birth after previous caesarean birth, Green top Guideline. No.45, 2007p1-17.

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10: Labour Analgesia

Relief of pain during labor & delivery is an essential part in good obstetric care.

Goals of Labour Analgesia- reduce pain of labor

 Should allow parturient to participate in birthing experience
 Minimal motor block to allow ambulation
 Minimal effects on fetus
 Minimal effects on progress of labor
Criteria of ideal analgesia:
• Efficient pain relief
• Should not depress the respiratory centre of fetus
• Should not affect the progress of labor
• Should be easily administered & convenient
• Good therapeutic safely
Types of Labour Analgesia
1. Non-pharmacological analgesia
a) Psycho prophylaxis
b) Ancillary support
i) Position
ii) Acupuncture
2. Pharmacological
a) Systemic
i) Opiod analgesia
ii) Antispasmodic
b) Inhalation agents Entonox

c) Regional analgesia:-
i) Epidural
ii) Pudendal block
iii) Perineal infiltration
d) Patient controlled Analgesia
i) Entonox
ii) Inj Pethidine IM.

1. Non Pharmacological: Psycho prophylaxis

Antenatal
a) Relaxation & motivation can reduce the fear & apprehension to great extent.
b) Antenatal classes to alley anxiety by explaining the normal physiology of pregnancy & labour
c) Relaxation exercise.

Intranatal
a) Allow to walk around during labor.
b) Assume any comfortable position:- Dorsal, Squatting, semi squatting
c) Encourage breathing technique.
d) Presence of companion in labor (Husband or relatives).

Advantage
It reduces the need of analgesia.

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2. Pharmacological
a) Opioid Analgesia
i) Pethidine: most commonly used intranatal analgesia
ii) Morphine
i) Pethidine:
a) Drug of choice
b) Has strong sedative but less analgesic effect.
c) Generally used in active phase of 1st stage of labor.
Dose: 100mg I/M (1 mg/kg/BW)
Advantages:
a) Provide adequate analgesia.
b) Safe
c) Quick action as parenteral administration
d) Doses do not inhibit uterine contraction
e) Help to dilate cervix.
Pre-condition for Inj Pethidine
a) Don’t give too early because it causes prolonged labour
b) Don’t give late if anticipate delivery within 1-2 hours
c) Anti dote must be ready (Naloxone ),Dose for new born :0.1 to 0.2 mg/kg/dose I/M, may repeat in 3-5mins if no
response.(1 amp =2ml ). For adult – 0.4 mg to 2 mg S/C, I/M
d) Ranitidine to inhibit gastric acid production &
e) Emetic effect is counteracted by metoclopromide.

ii) Antispasmodic: Tiemonium methyl sulfate

By relieving spasm in later part of 1st stage of labour
Should be given IM only,can cause respiratory arrest if given IV

b) Inhalation agent
Entonox
a) Cylinders contain 50% N2O & 50% O2.
b) Approved for used by midwives.
c) It can be self administered.
d) Most commonly used inhalation agent during labour.

Side effect:-
i) Hyper ventilation.
ii) Hypocapnia.
iii) Dizziness.

c) Regional analgesia
Epidural Analgesia
i) Provides excellent pain relief by reducing maternal catecholamines
ii) Ability to extend the duration of block to match the duration of labor
iii) Blunts hemodynamic effects of uterine contractions: beneficial for patients with preeclampsia.
Timing:- When the women is active phase of labour.
Monitoring:-
Pulse
BP 15 minute interval.
FHR
The women is kept in semilateral position to avoid aortocaval compression.

48 STANDARD CLINICAL MANAGEMENT PROTOCOLS AND FLOWCHARTS ON

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Advantages

i) Safest & simple method of pain relief when complete relief of pain is needed.
ii) Can top up the analgesic effect (repeated dose)
iii) Safe.
iv) Less risk of infection (as do not puncture the SA space)
v) No effect on fetal respiration.
vi) Can continue even after labour.
vii) Post operative analgesia can be given,
viii) Can be converted into anesthesia if needed.
ix) Reduced blood loss during labour ( as it causes symphathetic block) .
x) Cause peripheral pooling of blood so increased feto-placental circulation.
xi) So there is no fetal distress.

Disadvantage:

i) 2nd stage may be prolonged as because pt can not bear down.

ii) May require instrumental delivery.

Complication:-

i) Hypotension.
ii) Post spinal headache
iii) Pain at insertion site.
iv) Total spinal
v) Can paralyze the motor nerve.
vi) Unblocked segment.
vii) Risk of failure (10-15%)
vii) Urinary retention.

Pudendal nerve block

 Safe & simple method of analgesia during delivery.

 It dose not relieve the pain of labour but affords perineal analgesia & relaxation.

Indication:- Forcep & Vaginal breech delivery .

Addition: - Perineal & Vulval infiltration needed to block
Route -Transvaginal route:

Complication

i) Haematoma formation
ii) Allergic reaction
iii) Toxicity may affect.
iv) Tachycardia
v) Hypotension
vi) Arrhythmias
vii) Cardiac arrest
viii) Convulsion

Perineal infiltration:- By Local anesthesia

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Para-Cervical Block

PARACERVICAL BLOCK

A. Indication B. Precautions

• Dilatation and • Make sure there are no known

curettage allergies to lignocaine or related
• Manual drugs
vacuum • Do not inject into a vessel
aspiration

Counsel the client

C. Procedure
1. Load a 20 mL syringe with 20 mL of 1.0% lignocaine
(Or, 10 mL syringe with 10 mL of 2.0% lidocaine)
2. Introduce cusco to expose the cervix
3. Clean cervix with povidone iodine solution
4. Inject 2ml of 1%(1ml of 2%)lignocaine in the anterior lip Paracervical Block
of cervix at 12’O clock position, inject needle not more
than 1 cm. Wait for 1 min
5. Hold the anterior lip cervix with a volselum/tenaculum
forceps
6. Use slight traction to move the cervix and define the
transition of smooth cervical epithelium to vaginal
tissue. This transition marks the site of further injections
around the cervix.
7. Inject the remaining 18 ml in equal amounts at the
cervico vaginal junction at the 2, 4, 8, and 10 o’clock.
Inject continuously from superficial to a depth of 3 cm,
using a slow technique to decrease any pain to the
woman.
8. Remember to pull back on the plunger before injecting
anesthesia to prevent intravascular injection.
9. Wait for 2 minutes and then start the procedure.

Ref: Clinical Protocol on MENSTRUAL REGULATION, POSTABORTION CARE, POSTABORTION & POSTPARTUM FAMILY PLANNING.
Developed by: OGSB, RCOG and Ipas Bangladesh, November 2017

50 STANDARD CLINICAL MANAGEMENT PROTOCOLS AND FLOWCHARTS ON

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11: Flow Chart Postnatal Care

Definition: Care of Mother and Newborn from 1 hour after delivery, up to 6 weeks post-delivery.
Schedule of postnatal visit: First: within 24 hours; second: 2-3 days; Third: 4-7 days; Fourth: 42days.

Rapid assessment should be done before routine PNC care

Visit Mother New born
with History & Examination Investigation & Care & History & Counseling Care &
time Counseling Management Examination Management
1st visit: Within History taking Investigation ¨ Reassurance History taking ¨ Exclusive breast ¨ Delayed cord
0-24 hrs of ¨ Date time, place & ¨ CBC- if possible ¨ Explain ¨ Date, time and feeding clamping (1-3
delivery mode of delivery and if not done ¨ Medication place of delivery ¨ Keeping the baby min) & use of
¨ Duration of pregnancy during ANC/ - for pain ¨ Duration of warm chlorhexidine at
Place & Person: ¨ Duration of Labour otherwise Hb% - Supplement pregnancy ¨ Dry& wrap umbilical cord
Home or facility ¨ Any complain ¨ Blood group if not Iron-Ferous- ¨ Duration of ¨ Delayed bathing ¨ Reassurance
¨ Any H/O fever, done before. sulphate Labour (after 3 days) ¨ Explain
excessive bleeding, ¨ Blood sugar if baby Vit. A 2,00,00 IU ¨ Mode of delivery ¨ Immunization ¨ Medication
pain in lower abdomen, is big and if not single dosage (up ¨ Any complain ¨ Importance of if required
Headache. done during ANC to 14 days) ¨ Time of cry neonatal care ¨ Management
Examination Counseling Calcium + Vit D ¨ Bowel and ¨ Danger signs Of Birth
General ¨ Diet, Nutrition and ¨ Referral bladder habit asphyxia
¨ Pulse fluid ¨ Feeding habit ¨ Management
¨ BP ¨ Rest & exercise Examination of any
¨ Temperature ¨ Ambulation ¨ Birth weight complication
¨ Anemia ¨ Importance of PNC ¨ Color ¨ Referral
¨ Jaundice visit ¨ Respiration
¨ Edema ¨ General ¨ Umbilicus
Abdomen cleanliness/ ¨ Temperature
¨ Tenderness self-care ¨ Abdomen
¨ Height of Uterus ¨ Bowel & bladder ¨ Genitalia
¨ Uterus hard or soft ¨ Danger sign ¨ Spine
¨ Wound (if any) ¨ Any congenital
Breast anomalies
¨ Engorgement
¨ Redness
¨ Temperature
¨ Cracked nipple
Perineum
¨ Episiotomy wound
¨ Tear
¨ Swelling
¨ Vaginal Bleeding
¨ Vaginal discharge
- Amount
- Smell

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 Visit Mother New born
with History & Examination Investigation & Care & History & Counseling Care &
time Counseling Management Examination Management
2nd visit on 3rd History taking Investigation ¨ Reassurance History taking Exclusive ¨ Reassurance
day of delivery (If missed 1st visit) ¨ CBC- if possible & ¨ Explain (if not missed 1st breast feeding ¨ Explain
and 3rd visit on ¨ Date time, place & not done in 1st visit ¨ Medication visit) ¨ Keeping the ¨ Medication if
7-14 Days of mode of delivery ¨ Blood group if - for pain ¨ Date, time and baby warm Required
delivery ¨ Duration of pregnancy not done before. - Supplement place of delivery ¨ Immunization ¨ Management
¨ Duration of Labour ¨ Blood sugar if Iron Ferrous ¨ Duration of ¨ Importance of of any
Place & Person: Inquire about H/O GDM or DM. sulphate Calcium + pregnancy Neonatal care complication
Home or facility ¨ Any complain Counseling Vitamin D ¨ Duration of ¨ Care of the ¨ Referral
¨ Any H/O fever, ¨ Diet, Nutrition and - Vit. A (2,00,00 Labour baby ¨ Birth
excessive bleeding, fluid IU) single dosage ¨ Mode of delivery ¨ ECD ¨ Registration
pain in lower abdomen, ¨ Rest & exercise (up to 14 days ¨ Time of cry ¨ Danger signs
Headache, etc. ¨ Ambulation if not given in 1st Inquire about -Reluctant to feed
Examination ¨ Importance of PNC visit) ¨ Any complain -High pitched cry
General visit ¨ Referral ¨ Bowel and -Fever
¨ Pulse ¨ General bladder -Grunting or in
¨ BP cleanliness/ self habit drawing of chest
¨ Temperature care ¨ Feeding habit -Convulsion
¨ Anemia ¨ Bowel & bladder Examination -Yellow coloration of
¨ Jaundice ¨ Danger signs ¨ Weight eyes and body
¨ Edema -Severe bleeding ¨ Color -Discharge/bleeding
Abdomen after delivery ¨ Respiration from umbilicus
¨ Tenderness -Intense Headache ¨ Umbilicus
¨ Height of Uterus -Blurring of vision ¨ Temperature
¨ Uterus hard or soft -Fits/Convulsions ¨ Abdomen
¨ Wound (if any) -Foul smelling ¨ Genitalia
Breast vaginal discharge ¨ Spine
¨ Engorgement with fever ¨ Any congenital
¨ Redness abnormality
¨ Temperature
¨ Cracked nipple
Perineum
¨ Episiotomy wound
¨ Tear
¨ Swelling
¨ Vaginal Bleeding
¨ Vaginal discharge
- Amount
- Smell
4th visit on 42 History taking Investigation ¨ Reassurance History taking Exclusive breast ¨ Reassurance
days of delivery ¨ Any complain ¨ CBC- if possible & ¨ Explain (if not missed 1st feeding ¨ Explain
¨ Any H/O fever, not done in 1st visit ¨ Medication visit) ¨ Keeping the baby ¨ Medication
Place & Person: excessive bleeding, pain ¨ Blood group if - for pain ¨ Date, time and warm if required
facility in lower abdomen, not done before. - Supplement place ¨ Immunization ¨ Management
Headache, etc. ¨ Blood sugar if Iron Ferrous of delivery ¨ Importance of of any
Examination H/O GDM or DM. sulphate ¨ Duration of Neonatal care complication
General Counseling ¨ Referral pregnancy ¨ Care of the baby ¨ Referral
¨ Pulse ¨ Diet, Nutrition ¨ Duration of ¨ ECD
¨ BP and fluid Labour ¨ Complementary
¨ Temperature ¨ Rest ¨ Mode of delivery feeding
¨ Anemia ¨ Ambulation ¨ Time of cry ¨ Danger signs
¨ Jaundice ¨ Importance of Inquire about
¨ Edema PNC visit ¨ Any complain
Abdomen ¨ General ¨ Bowel and
¨ Tenderness cleanliness/ self bladder
¨ Height of Uterus care habit
¨ Uterus hard or soft ¨ Bowel &bladder ¨ Feeding habit
¨ Wound (if any) ¨ Danger signs Examination
Breast ¨ Birth weight
¨ Engorgement (for 1st visit )
¨ Redness ¨ Color
¨ Temperature ¨ Respiration
¨ Cracked nipple ¨ Umbilicus
Perineum ¨ Temperature
¨ Episiotomy wound ¨ Abdomen
¨ Tear ¨ Genitalia
¨ Swelling ¨ Spine
¨ Vaginal bleeding ¨ Any congenital
¨ Vaginal discharge anomalies
- Amount
- Smell

Note: Early Childhood Development (ECD)

52 STANDARD CLINICAL MANAGEMENT PROTOCOLS AND FLOWCHARTS ON

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Common physical problems during post-natal period and Actions

Presenting symptoms Ask/look/feel Probable diagnosis and Action

or complaints cause
• Excessive per vaginal • Amount: excessive or mild Delayed Post-partum • Fundal massage and assessment of the amount of
bleeding • When: after first 24 hours of delivery. hemorrhage (Presence bleeding
• Persistence: Continuous or irregular of bits of after births or • Injection ergometrine 2 ampl. I/M
• Odor: Foul Smelling infection after delivery) • Increased frequency of the breast feeding and rest
• Immediate refer to the hospital
• Foul smell discharge • Fever more than 1000F Puerperal Sepsis First line management
after childbirth • Pain in lower abdomen Antibiotic: Oral
• Tenderness in lower abdomen • Cap. Amoxicillin 500mg. 6 hourly
• Foul smell vaginal discharge • Tab. Metronidazole 400mg 8 hourly (IV if CSBA
herself is conversant to IV)
• Referral
• Leakage of urine, • Leakage of urine, continuous or when urge • Urinary tract infection/ • Sign and symptoms of urinary or fecal incontinence
stool and flatus • Smells of urine/stool Vesico vaginal fistula should be assessed during postnatal visits, during
• Difficulty to hold flatus • Rectovaginal fistula/ the first week after delivery, and at the 6-week
• Fecal incontinence: continuous or when complete perineal tear postpartum examination.
loose • Counseling regarding perineal strengthening
exercises.
• Referral
• Severe pain on the • Discoloration of overlying tissue Perineal hematoma • Painkillers
perineum • Swelling in the perineal area (Due to injury of blood • Antibiotics – Cephradine – 500 mg 6 hourly
vessels in the perineum • Refer as early as possible
during birth.)
• Pain in breast with • Usually only onebreast is affected Mastitis • Assurance
fever • Colour: Reddened, • Continue Breast feeding
wedge shaped area on breast • Routine expression of milk
• Tenderness: Present • Hot or cold compression
• When: 3 – 4 week safter delivery • Painkillers
• May lead to breast engorgement • Antibiotics if necessary –
- Cap. Fluclox – 500 mg 6 hourly for 5 days
- Cap. Cephradine – 500 mg 6 hourly for 5 days
• Referral
• Pain in lower • When: After delivery After pain (Due to • Massage the uterus
abdomen • Character: Pain is spasmodic presence of blood clots or • Painkillers
• Duration: 2-4 days after delivery bits after births) • Hot compression
• Painful wound • Pain at the site of wound Wound infections (Wound • Refer to the hospital
• Fever • Color: Redness around the wound may be at the Cervical/
• Swelling: Swollen Wound Perineal lacerations/
• Discharge: Foul smelling discharge at the episiotomy site or
site of the wound caesarian incision)
• Fever
• Pain in breast • Both breasts affected and associated with Breast engorgement • Assurance
discomfort • Continue Breast feeding more frequently
• Size: Enlarged • Show the mother position and attachment
• Consistency: Hard • Routine expression of milk
• Tenderness: Present • Hot or cold compression
• When: 3 – 5 days after delivery • Breast support
• Pain killer
• Referral
• Burning during • Fever: with chills Urinary tract infection • Advise her to drink plenty of water
urination • Pain and tenderness in lower abdomen (may be due to • Counsel her that she needs to go for urine
• Increased frequency catheterization or bladder examination and to visit a doctor
and urgency of trauma, lacerations or • Treat with Cap. Amoxicillin 500 mg 8 hourly for 5-7
urination, bruising) days
• Feeling unwell
• Pain& Swelling of the • Pain and Swelling: one leg or both Thrombophlebitis (due to • Use of compression stockings
leg and ankle • Color: Redness injury and inflammation of • Painkillers
• Tenderness: Present on the leg and ankle the blood vessel) • Bed rest
• Immediate referral to the physician
• Sore in nipple • Pain during breast feeding Cracked nipple • Correct positioning and attachment of baby to the
• Baby sucked the nipple only breast
• Mother avoids frequent feeding • Continue breast feeding
• Put breast milk, on sore area and dry in air.
• Swelling of legs • Dependent edema may present for few days Physiological edema • Assurance
• Check BP &Urine for protein • Rest

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Regular Immunization Schedule (0-11 m and 15 m old children): Measles and rubella vaccine-information booklet,
DGHS, Sept 2012

Disease Name of Amount Number Interval Appropriate Time Place of Route of

Vaccine Dose Dose between to start administration administrator
Doses
Tuberculosis BCG 0.5 ml 1 - After birth Left upper Arm Intra dermal
Diphtheria, Whooping Cough, Pentavalent 0.5 ml 3 4 weeks 6 weeks Outer side of Mid- Intra muscular
Tetanus, Hepatitis-B, Hemophylus Vaccine (DPT, thigh
Influenza-OB (Hib) Hepatitis-B Hib)
Pneumococcal Pneumonia PVC Vaccine 0.5 ml 3 4 weeks 6 weeks Outer side of Mid- Intra muscular
thigh
Poliomyelitis OPV 2 drops 4 4 weeks 6 weeks Oral Oral
Measles and Rubella MR 0.5 ml 1 - After completion Outer side of Mid- Sub dermal
of 9 m thigh (Right thigh)
Measles Measles 0.5 ml 1 - After completion Outer side of Mid- Sub dermal
of 9 m thigh (Right thigh)

Post-partum Family Planning

0 hours 48 hours 6 days 3 weeks 4 weeks 6 weeks 6 months 1 Year

LOCATIONAL AMENORRHEA METHOD

IMPLANT, MINIPILL (APON)

Breastfeeding
Women

IUD IUD IUD

TUBECTOMY IUD TUBECTOMY

INJECTION

COMBINED ESTROGEN POGESTIN

IMPLANT, MINIPILL (APON)

feeding Women
Non Breast-

IUD IUD IUD

TUBECTOMY IUD TUBECTOMY

INJECTION

COMBINED ESTROGEN POGESTIN

All Men

CONDOM

NSV

Reference:
1. WHO recommendations on postnatal care of mother and newborn
apps.who.int/iris/bitstream/10665/97603/1/97
2. Maternal Health Standard Operating Procedures(SOP) Volume-1

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12: Algorithm for Immediate or Routine Care at
Birth of Baby
STEPS OF ROUTINE/IMMEDIATE CARE
Ô Ô
Call out Time Tie/clamp and cut the umbilical cord within 1-3 minutes of delivery
with a sterile instrument
Ô Ô
Place baby on to mother’s abdomen (In case of C-section, keep Apply 7.1% Chlorhexidine on the umbilicus
the baby next to the mother on a clean surface)
Ô Ô
Dry the baby thoroughly. Give a quick look to see if there is any malformation/birth injury
(If amniotic fluid is meconium stained, clear mouth and then
nostrils with a mucous sucker before drying the baby)
Ô Ô
Remove wet cloth, Cover the baby’s head with a cap/cloth. Cover Place an identify label on the baby’s wrist
both mother and the baby with a warm cloth Weigh the baby
Put the baby skin-to-skin with the mother
Ô Ô
Assess, cry/breathing while drying. If the baby cries or breaths Initiate breastfeeding as soon as possible (no later than 1 hour)
normally proceed to next steps
Ô

Preparation for Delivery

• Identify a helper and explain role
• Make an emergency plan. Be prepared to act quickly to manage
problems such as asphyxia
• Prepare the delivery place (ensure privacy, light, warmth)
• Prepare a place for resuscitation
• Wash hands
• Prepare equipment and supplies and check functionality of the bag &
Mask and suction device.

Equipment and supplies • 7.1% Chlorhexidine

• Gloves • Suction device
• Two pieces of clean warm clothes • Bag & mask
• Cap • Stethoscope
• Thread/cord clamp • Clock/timer
• Scissors • Weighing scale

If there is no cry/breathing or the baby is gasping start resuscitation

Put the 1stknot 2 fingers from the abdomen, 2ndknot one finger away from the 1st knot. Milk the cord towards placenta and
put a 3rdknot 4 fingers from the 2nd.
Wash hands; or change gloves when necessary
Apply 7.1% Chlorhexidine on cut end of the cord, soak the body and the base completely. Keep the cord open and dry
Discard the used Chlorhexidine container
If chlorhexidine is not applied immediately after birth, apply within 48 hours

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13: Algorithm for Management of Perinatal Asphyxia

Dry baby with clean cloth and wrap

Ô
Look for Color: pink Yes Routine Care
Breathing well2/crying

Ô NO

 Clear the airway, if necessary Breathing well Routine care with close observation
 Position the head to open the airway
 Rub the back to stimulate for few
second

Ô Not breathing well

 Cut the cord long Breathing well Routine care with close observation
 Shift the baby to the resuscitation
table
 Start Bag and Musk ventilation within
one minute at a rate of 40 per minute
 Make sure that chest rises with each
squeezing
 Take Corrected measures at any
time if chest does not rise adequately
(improve ventilation)
 Ventilate for one minute

Ô Not breathing well

Check Heart Rate (HR) (feeling cord pulsation or by HR< 60/min Start CPR
listening with stethoscope)

Ô HR>60/min Ô
Continue to bag at a rate of 40 breaths per minute HR>60/min Check HR and Breathing
 Make sure the chest is moving adequately Not breathing well
 Every one minute stop and see if the HR and
breathing is improved Ô HR< 60/min
Stop bagging when the baby is breathing well and
HR > 100/min Consider to administer Drugs

• Adapted from SOP for Neonatal Health and Helping Babies Breath (HBB)

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If liquor is meconium stained, suction mouth first and then both nostrils, before drying

Breathing well: Breathing quietly and regularly or crying

Routine care:
• Keep warm (Skin-to-skin with mother)
• Cut cord (within 1-3 minutes)
• Check breathing
• Initiate BF

Not breathing well: Gasping or not breathing at all

Improve ventilation;
• Check mouth, oropharynx & nose for secretion; give suction if necessary
• Keep mouth wide open
• Reapply musk and make a better seal
• Reposition the neck
• Apply harder and longer squeeze

CPR: One CPR cycle comprises of 3 chest compressions plus 1ventilation. To give chest compression, hold the baby with
the fingers around the torso, thumbs in front, in the midline just below the nipple line, over the lower third of the sternum.
Depress the sternum to a depth of approximately one third of the antero-posterior diameter of the chest. Count “one and’.....
two and......three and............ (Give ventilation after counting three and’). Continue the cycles for 30 second and evaluate
breathing and heart rate to take the next action.

Drugs: Injectable adrenaline 1:1000 sol”: Mix 1 ml with 9 ml of distilled water to make a 1:10,000 dilution. Give 0.1-0.3 ml/
kg IV or 0.5-1.0ml/kg intra-tracheal

Additional Drugs:
• Injectable dextrose 10%: Give 2 ml/kg IV
• Injectable naloxone 0.4 mg/ml: Give 0.5ml/kg-if labouring mother received opiate within 4 hours of delivery.

Harmful resuscitation practices:

• Slapping the baby on the back
• Hanging upside down by the feet
• Milking the cord
• Routine suction of baby’s mouth and nose
• Throwing cold water on the baby’s face & body
• Giving glucocorticoid injections
• Blowing into the ears and nose
• Stimulating the anus
• Squeezing the rib cage
• Heating the placenta
• Dipping the baby’s cord alternatively in hot and cold water
• Bending the legs on the abdomen

Reference:
Dept. Health, Republic of South America 2014;Helping baby’s breath: American academy of pediatrics 2011; SOP: Standard operation procedure.

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14: Management of low birth weight babies

Low birth weight babies (LBW) are defined as babies with birth weight of <2500 gm irrespective of the gestational age.
Category of birth weight:
• Normal birth weight : Birth Weight 2500 - 4000 gm
• Low birth weight(LBW) : Birth Weight <2500 gm
• Very Low birth weight(VLBW) : Birth Weight <1500 gm
• Extremely Low birth weight(ELBW) : Birth Weight <1000 gm
• Incredible Low birth weight : Birth Weight < 750 gm

Type of LBW according to cause:

1. Preterm
2. Intrauterine growth restriction (IUGR)/SGA: Weight below the 10th percentile on the chart, for that gestational age.

Intrauterine growth chart

Problems of a preterm baby:

• Hypothermia
• Hypoglycemia
• Respiratory distress syndrome (RDS)
• Perinatal Asphyxia
• Apnoea
• Sepsis
• Intra ventricular hemorrhage
• Feeding Problem
• Necrotizing enterocolitis
• Hypocalcaemia
• Jaundice
• Congenital heart disease - PDA
• Retinopathy of Prematurity (ROP)

58 STANDARD CLINICAL MANAGEMENT PROTOCOLS AND FLOWCHARTS ON

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 Management of Low Birth Weight baby

Delivery room management:

• Ideally, the delivery of an anticipated LBW baby should be conducted in hospital with established newborn care
facilities.
• In-utero transfer of a LBW fetus is desirable, convenient and safe than the transport of baby.

Antenatal corticosteroid in preterm delivery:

• Antenatal corticosteroid therapy is a simple and effective therapy that prevents RDS in neonate.
• Recommended Dose: Inj Betamethasone 12 mg IM every 24 hrs X 2 doses or
¡ Inj. Dexamethasone 6 mg IM every 12 hrs X 4 doses.
• Given to mothers with preterm labour or APH or intended preterm delivery before 34 wks of gestation.

Principles of Management:

Rx of Complications

Keeping Management Fluid &

Warm Nutrition

Prevention
Management
Monitoring

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 Management algorithm

Deciding the place where a LBW baby should be managed

a) LBW babies weighing >1800 grams (>34 weeks): These babies are more or less stable. So, shifted to the mother
side in post natal care area, provided with extra assistance and monitoring as needed.

The training of mother during her stay include -

• Kangaroo Mother care (KMC) and assessment of temperature
• Breastfeeding
• Cup feeding may be needed
• Recognition/reporting of danger signs and
• Input all her queries related to care of a LBW baby.

b) Babies with birth weight below 1800 gm: These babies are more prone to develop all complications of low birth
weight. These babies should be admitted .

Indications for hospitalization

• Gestation: <34 week
• Birth weight <1800gm
• Any sick baby

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Thermal care:
Temperature can be maintained:
a) At Hospital
• Wrapping with extra layers of clothes
• Changing wet clothing
• Using radiant warmer, if available
• Breastfeeding
• Kangaroo Mother Care
• Nursing the baby next to the mother, as the mother herself is a good source of warmth for the baby
• Keeping the room warm (26-300 C) by heater

b) At Home
• Dress the babies with clothes, cap ,mitten and socks can be used for hand and foot
• Wrap properly with several layers of warm clothes or blanket.
• Immediate changing of wet clo.
• Kangaroo Mother Care (KMC)
• Keep door/window closed during winter
• Postponed bathing for first 72 hours and afterwards as per requirement
• Continue Exclusive Breast feeding

Feeding and nutrition:

Feeding of low birth weight (< 2500gms) babies differs from that of normal birth weight babies. These babies (especially those
< 1800 grams) often have difficulty in taking milk directly from breast and may require more help and ongoing monitoring.

Calories requirement in newborn:

For preterm infant: 110-140 kcal/kg/day

Feeding methods
• Gavage feeding (orogastric/ nasogastric feeding)
• Feeding by cup/cup-spoon. (alternate feeding method)
• Direct breast feeding

Initiation of Feeding:
Time of starting feeding and method of feeding should be individualized on the basis of birth weight, gestational age and
clinical conditions of the neonate.
• Start feeding as early as possible when hemodynamically stable.
• Abdominal examination shows– no distension, presence of bowel sounds, non- bilious gastric aspirates
• Having no sign of respiratory distress
• Having no risk factor for NEC.
• If Hemodynamically unstable start I/V fluid

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Modes of providing fluids and feeding:

1200-<1800gm
<1200gm and or ≥1800gm and or
Age and or
<30wks >34 wks
30-34 wks

Initial Nothing per oral Gavage(OG/NG) Breast feeding

I/V fluid feeding If unsatisfactory, expressed breast
Try Gavage ( OG/NG) feed if not milk (EBM) with cup or spoon
very sick Breast feeding

After 1-3 Gavage (NG/OG) feeding Feeding EBM with Breast feeding
days cup or spoon

Later(1-3 weeks) Feeding EBM with cup or spoon Breast feeding Breast feeding

After some more Breast feeding Breast feeding Breast feeding

time(4-6 weeks)

Choice of milk: Breast milk.

Signs of feeding intolerance

• Vomiting
• Abdominal distension and increase in abdominal girth >2cm from baseline at the level of umbilicus
• Gastric residuals >30% of previous feed or >3ml whichever is more
• Routine pre-feed gastric aspirates are not recommended

When to stop feed / withheld feeding

• Evidence of feeding intolerance
• Blood / bile stained gastric aspirate
• Reduced or absent bowel sound
• Systemic signs – cyanosis, bradycardia, lethargy
• Signs of systemic illness.ie, apnoea, shock, convulsion, respiratory distress

Counseling at discharge:
Mother and family must be counseled before discharge of the LBW neonate from hospital
Advice on discharge
• Provide exclusive breastfeeding
• Thermal protection at home
• When to seek care (“DANGER signs” ) and whom and where to contact
• Personal hygiene for prevention of infections
• Scheduled visits for assessing growth monitoring, detecting illness and providing immunization
• Mother’s nutrition and health
• Advise for a screen for ROP and Hearing evaluation for the babies who are very low birth weight 32 wk./<1500
grams)

Vaccinations in LBW babies:

If the LBW baby is not sick, the vaccinations schedule is the same for as the normal babies. Hence, BCG and OPV-0 should
be given at the earliest. A sick LBW baby however, should receive these vaccines only on recovery at discharge.

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15: Flow Chart for Management of Breastfeeding

Breastfeeding (BF) is the gold standard of infant feeding making strong bondage between mother and baby to provide
substantial health benefit for baby, mother and nation.
It protects the babies from many killer diseases & also protects women from non-communicable disease (NCD) as well.
Early initiation of breastfeeding within one hour of birth prevent newborn death by 31%
Though Breastfeeding (BF) is a natural act it is also a learn behavior. Mother and other caregivers require active support
for establishing and sustaining appropriate breastfeeding practices

WHO and UNICEF recommendation

1. Initiation of Breastfeeding within the 1st hour of life
2. Exclusive breast feeding for 6 months.
3. Breastfeeding on demand as often as the child wants
4. No use of bottle teats or pacifiers.

Breastfeeding Management

A. Preparation for BF B. Initiation of BF just after delivery C. Support during postpartum period
in Antenatal Period • Dry the baby first • Baby should stay with the mother in the same bed
• Counsel women • Put the baby on mother’s breasts for contact • Newborn should be nursed on demand (Baby led feeding)
about the and initiation of BF • Allow the baby to suck one breast until slips off and offer
benefits of BF & • Turn the baby’s whole body towards mother another if the baby wants
disadvantage of • Touch baby’s upper lip with mother’s nipple • Facilitate unrestricted breastfeeding
artificial milk when the baby opens mouth attach the baby • Start nursing from the previous unfed breast for
• Check for retracted onto the breast subsequent feeding
nipple Baby’s mouth should cover as much of the areola • Provide extra support for mother after C/S
• Demonstrate as possible (lower part must be inside baby’s • key points of position and attachment is to be followed for
technique of BF, mouth) prevention of breastfeeding problems
expression of • Counsel about the disadvantages of wrong • Management of breastfeeding problem as early as
breast milk. technique. possible

I. Key points of II. Key points of

position attachment
• Baby’s head and body • Baby’s mouth wide open
in a same line • Lower lip curled outwards
• Baby’s body close to • Most of the areola
mother including the lower part
• Baby’s whole body must be inside the baby’s
should be supported mouth
• He or she should be • Baby’s chin will touch the
facing the breast breast

III. Observation of BF IV. Bring mother to V. Expression of vi. Preservation of

• Documentation of breastfeeding during hospital stay the confidence that breast milk breast milk
- Condition of breast and nipple the baby is getting • Manual expression of • Up to 4-8hrours in
- Position of mother & baby enough milk breast milk is better room temperature
- Correct attachment • Passing urine at least • Press areola by the • up to 24hr in normal
- Frequency of feeding 6 times/day (5th day on thumb &index finger refrigerator (40C)
- Baby’s behavior all around. • up to 3 month in deep
- Number of wet cloth/diapers wards)
freeze
- Number & character of bowel movements • Baby is playing • up to 6 month in -200C
• Baby is sleeping well
• Baby is gaining weight

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 Algorithm for Management of BF

Provide antenatal preparation and breastfeeding education

Initiate early breastfeeding

Guide mothers to breastfeed

Monitor breastfeeding

Is breastfeeding effective?

Yes No

Continue breastfeeding Counsel and support

Appropriate intervention

Counsel for complementary feeding

after 6 months

Ref: 1. MOH NURSING CLINICAL PRACTICE GUIDELINE, SINGAPORE 2002.

2. Management of Breastfeeding for Healthy full terms infants revised in 2014

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16: Infant & Young Child Feeding (IYCF)

Recommended Feeding for Children up to Age Two (WHO Recommendation)

Newborn (Up to 6 months)
Begin breastfeeding within one hour of birth including colostrum; continue exclusive breastfeeding
(no other liquids or water) for six months (180 days)

Starting from 6 to 8 months

Introduce local family foods; half of a 250 ml bowl or bati of semi-solid or solid food two times a day, plus
two snacks/fruits, along with continued breastfeeding.

Starting from9 to 11 months

Rapidly increase amount of food for a young child to a half of a 250 ml bowl or bati of food three times a
day plus two snacks/fruits, along with continued breastfeeding.

Starting from 12 to 23 completed months

Rapidly increase food to one full 250 ml bowl or bati of food three times a day, plus two snacks, along with
continued& breastfeeding

Wash hands to protect food and health

Caregivers should wash their hands and the child’s hands with water and soap before food preparation
and feeding a child to prevent contamination of complementary food

Based on the National IYCF Strategy (IPHN 2007), the National IYCF Communication Framework and Plan (IPHN
2010), and the National Hygiene Promotion Strategy for the Water Supply and Sanitation Sector in Bangladesh, 2011,
Policy Support Unit, Local Government Division, MoLGRD& C

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 Complementary Feeding

Baby 7 to 8 completed months

• Give mashed family foods: Solid/Semi Solids
• Give fish or egg or chicken liver daily + concentrated dal + Shak or yellow fruits/vegetable + fried foods and food made with cow’s
milk
• Feed ½ bati (250ml) two times a day

Baby 9 to 11 completed months

• Spend time and teach child to feed himself/herself
• Give fish or egg or chicken liver daily + concentrated dal + Shak or yellow fruits/vegetable + fried foods and food made with cow’s
milk
• Feed ½ bati (250ml) three times a day and 1-2 time nutritious snacks.

Child 12 to 23 completed months

• Encourage child to feed himself/herself
• Give fish or egg or chicken liver daily + concentrated dal + Shak or yellow fruits/vegetable + fried foods and food made with cow’s
milk
• Feed one full bati (250ml) three times a day and 1-2 time nutritious snacks.

Vegetables

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17: Protocol for Antepartum Haemorrhage

Definition • Vaginal bleeding after 28 wks of pregnancy up to delivery of the foetus

Anticipate APH • PE, Chronic hypertension, renal disease, previous episode of bleeding in this
pregnancy
• Advanced maternal age, multiparity, previous CS, past H/O of APH,
polyhydramnios, PROM, multiple pregnancy

General Management • History: Gestational age, H/O Trauma, Amount of blood loss, Pain in lower
abdomen, tightness of abdomen
Clinical Examination:
• Pallor, Pulse, BP
• P/A: Contour of uterus, Tenderness, FHR
• P/V: Amount of blood loss
IV access:
• Blood for Hb%, grouping, Rh typing & cross matching.
• Start I/V fluid (Normal saline/Ringer Lactate)
• Blood transfusion (According to loss)
• Shock: Resuscitate as necessary- IV fluids, oxygen
• USG of uterus for pregnancy profile and localization of placenta (at labour room)
if not already known
• Reassurance &Counseling (keep ready at least 4 units of blood)

If expertise/facility
unavailable:
• Provide first aid
• Counsel patient
& family
• Refer

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 Flow chart for Specific Management of Antepartum Haemorrhage
(According to cause of hemorrhage)

APH

Bleeding from Placental Site Other than Placental Site

Placenta Praevia Abruptio Placenta

Painless, apparently, causeless, Shock, continuous abdominal pain or Gentle speculum examination
recurrent bleeding woody hard after exclusion of PP with USG
High presenting part Tense/tender uterus; Excessive show
Soft nontender relaxed uterus Normal/high/low BP Vagina: Trauma
FHS usually present FHS usually absent Cervix: polyp/cancer
Shock USG: placenta in upper segment (Treatment according to the
USG-placenta praevia cause)

Severe Active Bleeding slight/stopped Catheterization; ARM

bleeding Analgesic (Pethedine)
Continues Bed side clotting test to rule out DIC

Arrange for CS Premature Term or dead/ Heavy Bleeding slight/moderate

irrespective of Alive fetus severely bleeding
fetal maturity malformed fetus
and type of Steroid for lung
placenta maturation Confirm diagnosis
praevia Expectant Plan delivery
If Foetus is management till
alive and < 34 maturity/recurren Low lying Marginal If If delivery
wks Inj steroid ce of heavy delivery imminent
P/V & central
as early as bleeding not Expedite Foetus Foetus dead
bleeding is placenta
possible. imminent by VE/ alive/distressed or too
slight- praevia
Forceps Term/near term premature
vaginal when
Delivery not
delivery imminent maternal
may be Unsatisfactory condition is
possible by LUCS stable,
progress of
induction, labour (after cooperative
Vaginal
ARM oxytocin and bleeding
LUCS delivery
augmentation & stops after
followed by
ARM) ARM
Oxytocin
infusion

If excessive
DO NOT DO PV bleedings
EXAM do LUCS LUCS Vaginal
in placenta Praevia delivery

Note: Inj. Dexamethasone 6mg 12 hourly 4 doses for 48 hrs.

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 Antepartum Haemorrhage

Coagulopathy (Clotting Failure)

Coagulopathy is both a cause and a result of massive obstetric hemorrhage. It can be triggered by abruption placenta,
fetal death in-utero, septic abortion, eclampsia, amniotic fluid embolism and many other causes. The clinical picture
ranges from major hemorrhage, with or without thrombotic complications, to a clinically stable state that can be detected
only by laboratory testing.

Note: In many cases of acute blood loss, the development of coagulopathy can be prevented if blood volume is restored
promptly by infusion of IV fluids (normal saline or Ringer lactate) and blood transfusion.

• Treat the possible cause of coagulation failure

¡ abruptio placenta
o eclampsia
• Use blood products to control hemorrhage
¡ Give fresh whole blood replace clotting factors and red cells;
¡ If fresh whole blood is not available, choose one of the following based on availability
• fresh frozen plasma for replacement of clotting factors (15 ml/kg body weight);
• packed (or sedimented) red cells for red cell replacement
• cryoprecipitate to replace fibrinogen
• Platelet concentrates (if bleeding continues and the platelet count is less than 20,000)

Reference:
1. Antepartum Haemorrhage, Royal College of Obstetricians &Gynecological, Green-top guideline No-63, Nov-2011.

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18: Management Protocol of Postpartum Haemorrhage

 Excessive per vaginal bleeding >500 ml following vaginal delivery & 1000 ml following C/S
or any amount of bleeding which deteriorates maternal condition after child birth
Definition
 Symptoms: Bleeding P/V, giddiness, palpitation and shortness of breath.
 Signs: Rapid pulse, low BP, pallor, tachypnea or Shock

 Primary PPH: Excessive per vaginal bleeding after delivery within 24 hours
Identify PPH  Secondary PPH: Excessive per vaginal bleeding after 24 hours of delivery up to 6 weeks
post-partum.

 Prepare and be aware of PPH for every birthing women

 Anticipate PPH (High risk) - *Past H/O of PPH, * In present pregnancy: Hypertension, APH,
Anticipate PPH prolonged labour, multiple pregnancy, polyhydramnios * instrumental / operative delivery,
*injudicious use of oxytocin, *chorioamnionitis, *anaemia ( anemia in pregnancy should be
investigated and treated)

Management of Primary PPH

Primary Care During Antenatal Care
Level  Prepare and be aware of PPH for every birthing women (arrangement should always be
1.a. At ready)
Community  If PPH is anticipated àRefer to nearby Upazila Health Complex (where functioning
Clinic Level CEmONC is present) or to secondary level or tertiary level hospitals (the closest one)
(Allocated
service provider: During Intra-natal Care
CHCP, CSBA  Stabilization of patient
 If PPH is anticipated à refer to Upazila Health Complex (where functioning CEmONC is
present)
After Delivery
 Active management of 3rd stage of labor for prevention of PPH
 Postpartum haemorrhage àdue to uterine atony
• Intravenous fluid (Hartman Saline)
• Uterine massage
• Uterotonic drugs (Oxytocin, misoprostol)
• Bimanual compression
• Condom tamponade (Sayeba’s Method- needs training) & transfer to higher centre.
 Genital tract trauma – identify and refer.
 Refer to nearby Upazila Health Complex (where functioning CEmONC is present) or to
nearest secondary/tertiary level hospitals (the closest one).
 Aggressive resuscitation should continue and regular communication with the
receiving unit is essential (Mobile phone Communication)

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Primary Care During Antenatal Care
Level  Anticipate PPH

1.b At Union  If PPH is anticipated àRefer to nearby Upazila Health Complex (where functioning
Health & CEmONC is present) or to secondary level or tertiary level hospitals (the closest one)
Family During Intra-natal Care
Welfare  Anticipate PPH
Centre (UH &
 If PPH is anticipated àRefer to nearby Upazila Health Complex (where functioning
FWC)
CEmONC is present) or to secondary level or tertiary level hospitals (the closest one).
(Service provider:
FWV, SACMO  Aggressive resuscitation should continue and regular communication with the
receiving unit is essential
After Delivery
 Active management of 3rd stage of labor
 Primary Postpartum haemorrhage àdue to uterine atony
• Intravenous fluid (Hartman saline)
• Uterine massage
• Uterotonic drugs (Oxytocin/ergometrine /misoprostol)
• Tranexamic acid ( Oral 1gm/or 10 cc I/V slowly)
• Bimanual compression
• Condom tamponade (Sayeba’s Method- needs training) & transfer to higher centre.
 Genital tract trauma – identify and repair, refer if needed
 If bleeding not controlled Refer to nearby Upazila Health Complex (where functioning
CEmONC is present) or to secondary level or tertiary level hospitals (the closest one)
 Aggressive resuscitation should continue and regular communication with the
receiving unit is essential ( Mobile phone communication )

Primary Care During Antenatal Care

Level • Anticipate PPH
1.c At Upazila • If PPH is anticipated for placenta accreta or placenta previa
Health with previous Caesareanà refer to tertiary level hospital
Complex During Intranatal Care
(Consultant, MO, • Anticipate PPH
SSN)
• If PPH is anticipatedà Give general management:
o Wide bore IV cannula
o Hartman Saline
o Counsel patient and party (Guardian)
o Keep blood ready in hand
Refer to nearby secondary/tertiary level care (the closest one), if
it is a case of Placenta accreta and Placenta previa with history of
previous caesarean section.
 Aggressive resuscitation should continue and regular communication with the
receiving unit is essential
(Mobile phone communication)

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 After Delivery:
AMTSL for prevention of PPH
Postpartum haemorrhage
i. Uterine Atony
• Hartman saline IV (1L) with 20 IU oxytocin to infuse in 15 min and next 1 L within 30
mins, then regulate the rate of infusion until pulse settle down <100 b/min and systolic
BP >100mm of Hg
• Inj. Ergometrine 0.2mg IM /IV or Tab. Misoprostol 800-1000mcg PR
• Tranexamic acid (slowly 10cc I/V, oral 1 gm)
• If bleeding continued- Complete blood count
• Bimanual compression
• Condom tamponade (Sayeba’s method), & transfer to higher centre if needed.
ii. Genital tract trauma – identify & repair
iii. Bleeding disorder: diagnose, fresh blood transfusion/treatment according to cause
Refer to nearby secondary/tertiary level care if it’s a case of Placenta accreta and
Placenta previa with history of previous caesarean section or if other high risk factors are present.
 Aggressive resuscitation should continue and regular communication with the
receiving unit is essential (Mobile phone communication)

2. Secondary During Antenatal Care

Level Care Anticipate PPH
(Consultant, MO, • Keep blood ready (at least keep 2 donors ready) in hand
SSN) • Check for emergency preparedness of the center
Refer to nearby tertiary level care if it is a case of Placenta accrete/percreta or Placenta praevia
with history of previous caesarean section
During Intranatal Care
Anticipate PPH
• Prepare for general management:
• Arrangement for ABC management
• IV access with wide bore cannula
• IV Fluid if needed
• Blood grouping, cross matching and keeping donor ready
• Counseling and keep the family informed
After Delivery
AMTSL for prevention of PPH
Postpartum haemorrhage
i. Uterine atony (A)
• IV Hartman saline(1L) with 20 IU oxytocin to infuse in 15 min and
next 1 L within 30 mins then regulate the rate of infusion until
pulse settle down <100 b/min and systolicBP >100mm of Hg
• Uterotonic drugs
 Inj. Ergometrine 0.2mg IM /IV
 Tab. Misoprostol 800-1000mcg PR
• Tranexamic acid (slowly 10cc I/V, oral 1gm)
• Complete blood count, coagulation profile
• Uterine massage
• External Aortic compression
• Bimanual compression
• Exploration of uterus/ Urinary Catheter
• Condom tamponade (Sayeba’s method)
If Continuous bleeding –
Operative intervention
a. Laparotomy
i. Conservative Surgery: By preserving uterus

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 • B-Lynch method or modified B-Lynch
• Uterine artery ligation
• Ovarian artery ligation
ii Hysterectomy
b. Genital tract trauma – identify and repair
c. Bleeding disorder: diagnose, fresh blood transfusion/treatment according to cause

Refer to nearby tertiary level care center if PPH is anticipated for Placenta previa with history of
previous caesarean section, placenta accrete/percreta& local support is inadequateà
• counsel patient and the family
• refer to tertiary level hospital
 Aggressive resuscitation should continue and regular communication with the
receiving unit is essential

3. Tertiary During Antenatal Care

level care: • Anticipate PPH
Consultant, MO, • If PPH is anticipated for placenta accreta, percretaàcounseling and keep the family informed
Professor, senior • Keep donor ready (at least 4 donors)
Obstetrician, During Intranatal Care
Obstetric • AMTSL for prevention of PPH
Anesthetist, • Anticipate PPH
Gynecological If PPH is anticipated due to intrapartum risk , inform PPH team
Oncologist, If high risk- give General management:
Urologist, • Arrangement for ABC management
Interventional • IV access with wide bore cannula
radiologist, • Hartman Saline IV
Intensive care • Catheterization
specialist, • Blood grouping, Rh typing, cross matching and keeping donor ready
Neonatologist. • Counseling and keep the family informed
After Delivery
AMTSL for prevention of PPH
Postpartum hemorrhage
Uterine atony (A)
• Hartman solution IV(1L) with 20 IU oxytocin to infuse in 15 min and next 1 L within 30 mins
then regulate the rate of infusion until pulse settle down <100 b/min and systolicBP >100mm
of Hg
• Uterotonic drugs
 Inj. Ergometrine 0.2mg IM /IV
 Inj. Carbetocin 100 mg I/V slowly stat
 Tab. Misoprostol 800-1000mcg PR
• Tranexamic acid (10cc1/Vslowly, Oral 1gm)
• Complete blood count, coagulation profile
• Bimanual compression
• Exploration of uterine cavity
• Condom tamponade (Sayeba’s method)
• External Aortic compression
i. If refractory bleeding- PPH team: Obstetrician, Obstetric Anesthetist, Gynecological Oncologist,
Urologist, Interventional Radiologist, Intensive care specialist, Neonatologist, should be
informed and ready
Operative intervention
Laparotomy:
. i. Conservative Surgery: By preserving uterus
• B-Lynch method or modified B-Lynch
• Uterine artery ligation
• Ovarian artery ligation
ii. Hysterectomy(keep ready ICU bed)

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19: Protocol & Flowchart for Management of
Ruptured Uterus
Signs and Symptoms  Vaginal bleeding after 28 wks of pregnancy, in labour and after delivery
 Rapid pulse, pallor, low BP, restlessness, other signs of shock, suprapubic pain and
tenderness
 Distended & tender abdomen, loss of uterine contour, absent Foetal movement/Foetal heart
sound
 Sense of something giving away with collapse

Suspect  Obstructed labour/transverse lie especially in multipara; H/O previous CS, myomectomy,
Ruptured Uterus hysterectomy; fall/blow on abdomen, forcible external cephalic version/internal podalic
version: injudicious use of oxytocin, difficult manual removal of placenta, difficult forceps/
breech extraction: placenta accreta

General Management  Assess severity of symptoms

 Exam: Palor, Pulse, BP, feeling & contour of uterus, FHR, PV blood loss
 Shock: Resuscitate as necessary, IV access, blood for Hb gr. & Rh and cross match. Start
Hartman solution or normal saline, replace blood
 Reassurance & Counseling; Explain the situation and need for immediate interference/type of
interference

If expertise/facility unavailable:
• Provide first aid
• Counsel patient & family
Ruptured Uterus • Refer with proper referral sheet

Laparotomy& surgical management

Incomplete rupture

(Peritoneum intact) Complete rupture (All layers disrupted)

Deliver baby & placenta & clean the abdominal cavity

• Caesarean Section, Repair of uterus Repair with sterilization Subtotal Total

deliver baby and complete hysterectomy/ hysterectomy
procedure Caesarean
• Infuse oxytocin 20 units • If repairable • If repairable hysterectomy If tear
in 1L NS @60 drops/min • Edge of the • Edge of the tear not extends
until uterus contracted tear not necrotic through
then necrotic • Does not want to cervix and
• Want to preserve fertility/ Uterus unrepairable vagina &
@ 20 drops/min
preserve Prefers sterilization/ unrepairable
fertility Badly damaged uterus

In all cases check for injury

of the urinary bladder, if
identified: repair the injury

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20: Flowchart for Management of Obstetric Shock

Shock is characterized by failure of the circulatory system to maintain adequate perfusion of the vital organs.
Shock is a life threatening condition that requires immediate and intensive treatment

Shock in obstetrics may occur due to Bleeding, Infection& Trauma in pregnancy and postpartum period
Causes:
Bleeding in pregnancy and/ (1) Early pregnancy: Causes are abortion, ectopic and molar pregnancy
Postpartum (2) Late pregnancy &labour: causes are placentae praevia, abruption placentae, ruptured uterus
(3) Post-partum: causes are PPH due to uterine atony, Injury to genital tract, retained placenta or
Infection: placental fragments,
Trauma: Septic abortion, amnionitis, metritis, acute pyelo nephritis.
Causes are uterine and bowel injury during abortion, ruptured uterus, tears of the genital tract.

Signs and Symptoms • Consciousness : Confused, no response to verbal stimulation or to pain (coma)
• Skin : Cold, clammy, pallor
• Pulse, BP : Rapid, low volume (more than 110 per minute). Low blood pressure
• Respiration (systolic BP less than 90mmHg)
• Hydration : Rapid/air hunger /gasping
• P/V examination : Dehydrated, low urine output (less than 30 ml/hr.)
: According to the cause of shock

Immediate Management • Shout for help; Left lateral position

• Placement of two large bore cannula, IV fluid (Crystalloid or colloid solutions) if a peripheral vein
cannot be cannulated, perform venous cutdown (venesection)
• Blood for Hb, Gr & Rh and cross-match,
• Start Normal saline/Ringer’s lactate
• Continuous catheterization: intake output chart
• Monitor vital signs: pulse & BP every 5 mins until stable, respiration temperature; urine output
• Keep patient warm by covering with blanket
• Foot end raised
• Reassure and keep patient and family informed, explain the situation and need for immediate
intervention
• Urgent Inv grouping and Rh typing, cross match, Hb, hematocrit, bed side clotting test

Specific Management

Hemorrhage Infection Others

• Resuscitation • If infection is suspected as the cause • Eclampsia see protocol
• Control bleeding • Collect appropriate samples (blood, urine, HVS, • CVA
• Replace blood Pus) for microbial culture before starting antibiotics • Cardiac causes
• Find out the cause and give • Give combination of antibiotics covering aerobic • Pulmonary embolism
treatment according and anaerobic infections. • Drug reaction hypoglycemia
• Ampicillin 2g IV 6 hourly, Plus gentamicin 5 mg/kg • hepatic shock
IV every 24 hours • Amniotic fluid embolism
• Resuscitation • Treat accordingly/Refer
• Antipyretic

Reassessment: Signs of improvement are:

• Stabilizing pulse (90 per minute or less)
• Increasing BP (systolic 100 mmHg or more)
• Improving mental status
• Increasing urine output (30 ml per hr. or more)

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21: Protocol for Management of PROM

Definition Rupture of the fetal membranes before onset of labour

 Term PROM: ≥37+0 weeks
 Preterm premature rupture of membranes (PPROM):<37 weeks’ gestation.

Diagnosis • Maternal history: H/O gush of fluid P/V

Symptoms &Signs • Per speculum examination (sterile) to see
 Fluid coming through the cervix
 Fluid coming through cervix during coughing
 Typical odour of amniotic fluid confirms the diagnosis
 Ask the patient to place a vaginal pad over vulva & examine it 1 hour later (In suspected cases)
• For Diagnosis
Nitrazine test to detect pH change If available
 Fern test
 Fetal Fibronectin : (present in endocervix or the vagina in 93.8% cases)
 Ultrasound (helps to confirm the diagnosis)

General Management • Confirm gestational age

• Ask for pain, fever, foul smelling P/V discharge, Foetal movement
• Assess pulse, temperature, uterine tenderness, liquour volume, uterine contraction, FHR, and vaginal
discharge
• Investigations : CBC, Urine RME, High Vaginal swab (HVS) for C/S, C-reactive protein (CRP), USG to
see fetal wellbeing and liquor volume (AFI)

Special Note: Do not perform a digital vaginal examination

Management
 ≥36 weeks : Active Management ( Can wait for 24 hours for spontaneous onset of labour)
 32-<36 weeks :
- Immediate induction and delivery after antibiotics and steroids administration (if gestational age <34, delivery 24 hours after
the last steroid injection) if there is sign of infections (Leukocytosis >16000/cu mm> , CRP > .9mg/dl , largest pocket of amniotic fluid <
2cm, variable deceleration and poor variability CTG, Cervical length <1.5cm with funneling
- Otherwise Expectant management:
 Hospitalization
 Antibiotics
 Antenatal corticosteroids (<34 weeks)
 Tocolytics only to get benefits of steroid administration/window for transporting to referral center
 Maternal & Fetal Monitoring

 >24- <32weeks: Expectant management.

 Hospitalization
 Antibiotics administration
 Steroids administration
 Maternal & Fetal Monitoring
Tocolytics for 2 days if there is uterine contraction on admission to get benefits of steroid administration

 <24 weeks: Counseling & termination ( as no management can improve prognosis ) : Follow the protocol for termination of pregnancy

Note: Dose of cortico steroid: Inj. Dexamethasone 6 mg 12 hourly I/M 4 doses for 48 hours
Do not use steroid in presence of infections

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 Flow Chart

a. Preterm PROM (24-36) Term > 36 wks

A. Expectant Management
Chorioamnionitis
b. No evidence of chorioamnionitis B. Active
 Hospitalization Management Foetal distress
 Consider transfer to the most appropriate
Foetal death
Service for care of the neonate
Antibiotics : Regimen1 Foetal anomaly
 Corticosteroids for lung maturity
 Maternal Monitoring : Maternal sign of
• Clinical 4 hourly (Temp, maternal chrioamnionitis
pulse, uterine tenderness, P/V foul Consider
smelling discharge) Fever(≥100.4o + any
• Laboratory test: Blood for CBC, two or more • Antibiotics : Regimen 1
C-reactive protein, Urine for RE
• Corticosteriods- Regimen 2
• High Vaginal swab for CS & USG  Maternal pulse • Consider transfer to facility with NICU if
>100bpm possible
 Fetal monitoring  FHR >160bpm • Induction of labour-If vaginal delivery feasible
 uterine • Consider C/S
• SFH (Symphysio Fundal Height) tenderness  Foetal distress
• FHS-Foetal distress  foul smelling PV  Failed induction
• Color of liqour discharge  Unsatisfactory progress of labour
• CTG  Leukocytosis  Malpresentation
• USG-growth & BPP >15000  Previous C/S
 C-reactive protein
>2.7mg/dl
 No other site of
infection
Consider Active Management
- If 36 wks
-chorioamnionitis
-Foetal distress
- Labour

Foot Note: Regimen

Regimen 1: Antibiotics: -Inj. Ampicillin/Cephalexin IV for 48 hours followed by Erythromycin 250 mg qds + Amoxicillin 500
mg tds- until delivery (NICE Guideline)
If chorioamniotitis develops give injectable combination antibiotics: ampicillin (2 gm) IV 6 hourly + gentamicin (5 mg/kg)
IV every 24 hours + Metronidazole IV (500 mg) 8 hourly until the patient is fever free for 24 hours
Source: Integrated management of pregnancy and childbirth managing complications in pregnancy and childbirth (MCPC)
Regimen 2: Corticosteriods for lung maturity: if < 34 wks – Inj. Dexamethasone (6mg) IM 12 hourly for total 4 doses

Ref:
1. Preterm Pre-labour Rupture of Membranes (Green-top Guideline No. 44).
https://www.rcog.org.uk/en/guidelines-research-services/guidelines/gtg44 Oct 1, 2010
2. Practice Guidelines. ACOG Guidelines on Premature Rupture of Membranes. Am Fam
Physician. 2008 Jan 15;77(2):245-246.
3. Practical guide to High Risk pregnancy 3rd edition By Fernando Arias. Page 240
4. Pocket Book of Hospital care for mothers (Guidelines for management of common maternal conditions). WHO
(2017 edition):189
http://www.searo.who.int/entitymaternal-reproductive_health/en

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22: Preterm labour

Preterm delivery is associated with high perinatal morbidity and mortality.

Diagnosis
 Labour occurring before 37 weeks of gestation.
• Palpable regular contractions
• Blood-stained mucus discharge (show) or watery discharge
 Sometimes
• Cervical dilatation and effacement
• Light vaginal bleeding
Confirm the diagnosis of preterm labour by documenting cervical effacement or dilatation over 2 hours.
Management
Consists of giving cortico steroids, tocolysis and or allowing labour to progress. Maternal problems are chiefly
related to interventions carried out to stop contractions.
Attempt tocolysis if:
• Confirmed gestational age <37weeks
• Cervix is<3cm dilated
• no amnionitis, preeclampsia or active bleeding
• no fetal distress
Note: This intervention aims to delay delivery until the effect of cortico steroids has been achieved
Tocolytic
Give a to colytic drug and monitor maternal and fetal condition (pulse, blood pressure, signs of respiratory distress,
uterine contractions, loss of amniotic fluid or blood, fetal heart rate, fluid balance, blood glucose).
Corticosteroids
Antenatal Corticosteroids given to the mother
 To improve fetal lung maturity and chances of neonatal survival
 Considerable reduction in the risks of complications of prematurity such as:
 Respiratory distress syndrome
 Intraventricular haemorrhage
 Perinatal death
Antenatal corticosteroid therapy is recommended for women at risk of preterm birth from 24 wks to 34 wks of
gestation when the following conditions are met:
• Gestational age assessment can be accurately undertaken.
• Preterm birth is considered imminent.
• There is no clinical evidence of maternal infection.
Dose :
Give betamethasone 12 mg IM, 24 two doses hours apart OR
Dexamethasone 6 mg IM, four doses 12 hours apart.
A repeat course of antenatal corticosteroid is recommended if preterm birth does not occur within 7 days after the initial
dose, and a subsequent clinical assessment demonstrates that there is a high risk of preterm birth in the next 7 days.
Note: Corticosteroids should not be used in the presence of frank infection. If preterm labour continues despite use of to colytic drugs, arrange for
the baby to receive care at the most appropriate service with neonatal facilities. If needed and possible, refer the woman before she gives birth.

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Table. Tocolytic drugs to stop uterine contractions

Drug Initial dose Subsequent dose Side effects and precautions

• Nifedipine • 10-30 mg stat • Followed by 10-20mg • Contraindications: hypersensitivity

(preferred every 4-8 hours (titrate to drug, CHF, Hypotension
drug) according to uterine • Side effects: flushing, dizziness,
activity) for up to 48 palpitations
hours or until transfer is
completed, whichever
comes first.

• Indomethacin • 100 mg loading • Give 25 mg every six • If gestation is more than

dose by mouth hours for 48 hours 32 weeks, avoid use
or rectum to prevent premature closure of fetal
ductus arteriosus. Do not use for
more than 48 hours.

When tocolysis is considered in this context, nifedipine (a calcium channel blocker) is the preferred choice.

Note: Prophylactic antibiotic treatment for preterm labour with intact membranes is not recommended.

Magnesium Sulphate:
The use of magnesium sulfate is recommended now a days for women at risk of imminent preterm birth before
32 weeks of gestation for prevention of cerebral palsy in the infant and child.
 There are three dosing regimens :
 IV 4 g over 20 minutes, then 1 g/hour until delivery or for 24 hours, whichever came first
 IV 4 g over 30 minutes or IV bolus of 4 g given as single dose
 IV 6 g over 20–30 minutes, followed by IV maintenance of 2 g/hour

There is insufficient evidence to recommend one specific dosing regimen over others .
 Allow labour to progress if:
 The cervix is more than 3 cm dilated
 There is active bleeding
 The fetus is distressed, dead or has an anomaly incompatible with survival
 There is amnionitis or preeclampsia
 Monitor progress of labour using the partogram
Note: Avoid delivery by vacuum extraction, as the risks of intracranial bleeding in the preterm baby are high.
 Prepare for management of preterm or low birth weight baby and anticipate the need for resuscitation.

Reference:
1. WHO guidelines for management of common maternal conditions, Pocket book for Hospital care of mothers, 2017ed.p-234
a. To enter into routine β-hCG follow-up protocol.

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23: Management Protocol for Hypertensive disorders in
pregnancy at facility level

Definition:
Hypertensive disorders in pregnancy

Gestational hypertension
• Defined as systolic blood pressure ≥140 mm Hg and/or diastolic blood pressure (DBP) ≥90 mm Hg in a previously
normotensive pregnant woman after ≥20 weeks of gestation in the absence of proteinuria or new signs of end-
organ dysfunction.
The blood pressure readings should be documented on at least two occasions 4 hours apart

Preeclampsia: Occurrence of new-onset hypertension plus new –onset proteinuria after 20wks
Blood Pressure
• Greater than or equal to 140 mm Hg systolic or ≥90 mm Hg diastolic on two occasions at least 4 hours apart after
20 weeks of gestation, at the time or after delivery in a woman with a previously normal blood pressure.11
• Greater than or equal to 160 mm Hg systolic or ≥110 mm Hg diastolic, hypertension can be confirmed within a
short interval (minutes) to facilitate timely antihypertensive therapy.11 and
Significant Proteinuria
• Greater than or equal to 300 mg per 24-hour urine collection or
• Protein/creatinine ratio ≥0.3( each measured as mg/dl)
• Dipstick reading of 1+ (used only if other quantitative methods not available)

Mild preeclampsia/ Preeclampsia without severe features

• Two readings of Systolic BP 140 to<160mmHg & DBP ≥90 to <110mmHg4 hours apart after 20 weeks gestation.
• Significant proteinuria (≥0.3gm in 24 hrs urine) or Protein creatinine ratio 0.3 or≥1+ on Dipstick.
• No evidence of organ dysfunction.

Severe preeclampsia/ Severe features of Preeclampsia (Any of these findings)

• Systolic BP ≥ 160 mm Hg &or Diastolic BP ≥ 110 mm Hg after 20 weeks gestation on 2 occasionsat least 4hrs
apart
• Significant proteinuria (≥0.3gm in 24 hrs urine) or Protein creatinine ratio 0.3 or ≥1+ on Dipstick.
Or in the absence of proteinuria, new-onset hypertension with the new onset of any of the following:
• Thrombocytopenia- platelet count <100000/microliter
• Renal insufficiency- serum creatinine>1.1 mg.dl or a doubling of serum creatinine concentration
• Impaired liver functions- elevated liver transaminases ≥ twice normal concentration
• Pulmonary edema
• Cerebral or visual symptoms
Headache (increasing frequency, not relieved by regular analgesics).
Blurred vision.
• Oliguria (passing less than 400 mL urine in 24 hours).
• Upper abdominal pain (epigastric pain or pain in right upper quadrant)

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 Eclampsia
• New onset hypertension after 20 weeks gestation.
• Significant Proteinuria or ≥1+ on Dipstick.
• And sometimes.
o Altered sensorium or loss of consciousness.
o Other symptoms and signs of severe preeclampsia.
• Along with convulsions

Chronic hypertension
• Is defined as high BP known to predate conception or detected before 20 weeks of gestation or persists for
more than 12 weeks postpartum Women.
Chronic hypertension with superimposed preeclampsia in a patient of chronic hypertension if there is:
• Women with hypertension only in early gestation who develop proteinuria after 20wks gestation.
• Women with hypertension with proteinuria before 20wks of gestation who
a) Experience a sudden exacerbation of hypertension or need to escalate dose of antihypertensive drug
in previously well controlled BP
b) Sudden increase in liver enzymes to abnormal levels
c) Presence with decrement in platelet levels to below 100,000/ microliter
d) Manifest symptoms such as right upper quadrant pain and severe headache
e) Develop pulmonary edema
f) Develop renal insufficiency
g) Have sudden, substantial and sustained increases in protein excretion

Classification and Diagnosis of hypertensive disorders of Pregnancy based on

symptoms & Signs
Symptoms and Signs Symptoms and Signs Probable
Typically Present Sometimes Present Diagnosis
• Two readings of systolic BP _ Gestational
≥140mmHg or diastolic BP ≥ 90mm Hypertension
Hg 4 hours apart after 20 weeks’
gestation
• No proteinuria
• Systolic BP ≥140mmHg or diastolic _ Chronic
BP ≥ 90mm Hg or more during first Hypertension
20 weeks of gestation
Systolic BP ≥140mmHg or diastolic • Features of severe Preeclampsia Chronic
BP ≥ 90mm Hg or more during first hypertension
20 weeks of gestation and further with superimposed
rise of BP or new development of preeclampsia
Proteinuria ≥1+
• Two readings of Systolic BP _ Mild Preeclampsia
≥140mmHg or diastolic BP ≥ 90mm
Hg or more after 20wks gestation 4
hours apart
• Significant Proteinuria or
≥1+proteinuria

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Symptoms and Signs Symptoms and Signs Probable
Typically Present Sometimes Present Diagnosis
• Systolic BP ≥160mmHg or diastolic • Proteinuria might be absent Severe
BP ≥ 110mm Hg or more after 20 wks • Headache (increasing frequency, unrelieved by regular Preeclampsia
of gestation analgesics)
• Significant Proteinuria • Blurred vision
• Oliguria (passing less than 400 mL urine in 24 hours)
• Upper abdominal pain
(epigastric pain or pain in right upper quadrant)
• Pulmonary edema
• Convulsions • Coma (unconscious) • Eclampsia
• Systolic BP ≥140mmHg or diastolic • Other symptoms and signs of severe preeclampsia
BP ≥ 90mm Hg or more after 20
weeks of gestation
• Significant Proteinuria or ≥1+in dip
stick

Management of hypertensive disorders in pregnancy

• Women with preeclampsia (mild/severe) and eclampsia should be stabilized and immediately referred to a
CEmONC centre for management.
• Women with mild preeclampsia may rapidly progress to severe preeclampsia.

Gestational Hypertension/ Mild Preeclampsia

• Admission
• Monitor BP 4times a day
• Test for 24 hrs urinary protein – Do not repeat quantification of proteinuria
• Kick count daily
• Blood test: Twice a wk. (CBC, S creatinine, S electrolytes, s transaminases, Bilirubin) and urine parameters and
examination of retina for changes is advisable
• Ultrasonography to determine fetal growth every 3wks
• Women with systolic BP 140/90mmHg to 149/99mmHg - No antihypertensive. Oral Labetalol if BP is 150/100-
159/109mmHg, ((NICE)
• Discharge if BP normalizes and investigations are normal
• Follow-up twice weekly with weekly platelet counts and liver enzymes
• Monitor fetal growth, if signs of growth restriction consider early delivery

Severe preeclampsia
• Admit and Stabilize patient at CEmONC centre
• Principles of management:
- Admission
- Monitor BP at least 4 times a day
- 24hrs total urinary protein ( Do not repeat quantification of proteinuria)
- Monitor blood tests: 3 times a wk.(CBC, S creatinine, S electrolytes)
- Start antihypertensive: Oral labetalol
- Plan delivery
Magnesium Sulfate: Start MgSo4 (10gm prophylactic dose) (if DBP ≥ 110 mm Hg or symptoms like headache, upper
quadrant pain, blurring of vision present or persist)
For settings where it is not possible to administer the full magnesium sulfate regimen, the use of magnesium
sulfate loading dose followed by immediate transfer to a higher level health-care facility is recommended for
women with severe preeclampsia and eclampsia.

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Antihypertensive medications (Oral)
Drug Dose Side Effects
Methyldopa 250 mg tds(max 2g) Fatigue, depression
Labetalol 100 mg bd-tds (max 2400 mg) IUGR, hypoglycemia
Nifedipine 10 mg bd- tds (max 120 mg) Hypotension, headache

Drugs in hypertensive emergencies (defined as organ damage occurring because of

severely elevated BP, BP≥160/110)
Drug Dosage (LSS) Repeat

Labetalol 10 mg IV • If response to labetolol is inadequate (diastolic blood pressure remains above 110 mm
Hg) after 10 minutes, give Labetalol 20 mg IV; Increase dose to 40 mg and then 80 mg if
satisfactory response is not obtained after 10 minutes of each dose

Hydralazine 5 mg IV slowly over 5 minutes • Repeat hourly as needed or give hydralazine 12.5 mg IM every 2 hours as needed
until blood pressure is lowered

Nifedipine 5 mg oral • If response to nifedipine is inadequate (diastolic blood pressure remains above 110 mm
Hg) after 10 minutes, give an additional 5 mg

Management of Chronic Hypertension

• Encourage rest.
• Do not lower blood pressure below 120/80 mmHg. High levels of blood pressure maintain renal and placental perfusion in chronic
hypertension.
• If disease is well-controlled, continue the same antihypertensive if acceptable in pregnancy.
• Start antihypertensive if BP≥150/100.
• If proteinuria or other signs and symptoms are present, consider superimposed preeclampsia and manage as preeclampsia (see
Table 3.1)
• Monitor fetal growth and condition:
o If there are no complications, deliver at 37 weeks.
o If fetal growth restriction is severe and pregnancy dating is accurate, assess the cervix and consider delivery.

Eclampsia
General Management
• If the woman is unconscious or convulsing, SHOUT FOR HELP
• Rapid assessment and management should be done simultaneously.
• Check airway breathing & circulation (ABC)
• If she is breathing, secure airway gives her oxygen @ 4-6 L per minute by mask or nasal cannula
• If she is not breathing, assist ventilation using an Ambu bag & mask & give oxygen @4-6 L per minute by ambu bag or
endotracheal tube
• If the woman is convulsing/unconscious position her to left side (eclamptic position)
• Clear the mouth and throat as necessary.
• Protect her from injuries, but do not attempt to restrain her and never leave the women alone
• IV access --> IV fluid: Normal saline/Hartman’s solution
• Continuous catheterization to monitor urine output and proteinuria
• Give anticonvulsant drugs
• If diastolic blood pressure remains above 110 mm Hg and systolic BP more than 160 mm Hg, give antihypertensive drugs.
Reduce the diastolic blood pressure to less than 100 mm Hg but not below 90 mm Hg (this helps to maintain perfusion to the
fetus).
• Maintain strict fluid balance and intake output chart, prevent fluid overload (80ml/Hour, not more than 2 liters in 24 hours)
• Maintenance of nutrition: 24 hours after delivery if patient is unconscious:- give Ryle’s tube feeding - 250 ml fluid 2 hourly, if
conscious give oral feeding
• Antibiotics: Inj. Amoxycillin - 8 hourly/Ceftriaxone 1 gm 12 hourly
• Provide constant supervision
• Monitor Pulse, BP, respiration (>16/min), reflexes every 1/2 hrs.
• Monitor FHR, urine output, auscultate lung bases
• Care of the eye, skin and maintain oral hygiene
• Investigation: CBC, Bl gr & Rh typing, S creatinine, S, electrolytes, SGPT, Bilirubin, urine for protein, bedside clotting test,
Coagulation Profile

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Magnesium Sulphate Therapy

Control of convulsion
Facility Level

Magnesium Sulphate Therapy

IV/IM protocol (preferred regime)
IV/IM protocol

Dose Method

Mg. Sulphate 4g (8ml) Slow IV Injection over a period of 10-15 min

Loading in 12 ml dist. Water = 20ml
Dose
Mg. Sulphate Deep IM injection 3g in each buttock
(6g=12ml) I.M 3gm + 3 gm

Maintenance Mg. Sulphate Deep IM injection 2.5g every 4 hourly using

Therapy (2.5g=5ml) Alternate buttock. Continue for 24 hrs after
last convulsion or delivery

Inj. MgSo4 IV Protocol (Inj. Nalepsin)

Loading dose: Inj. Nalepsin - 4 gm in 100ml rapid IV @60-75 drops/min over a period of 20 minutes
Maintenance dose: (in the facility)
Inj. Nalepsin 100ml (4gm) @6-7 dpm [need 4 hrs to finish one bottle & continue 6 bottles for 24 hrs (4 x 6 =
24 gm)]
[ Inj. Nalepsin (4gm/100 ml) in 4 hrs
= 1 gm/hr. (i,e 25 ml/hr.)
= 25 ml x 15 drops/hrs( 15 drops /ml )
= 375 drops /60 min= 6-7 drops /min]

IM protocol (Community level)

(If skill provider to give IV injection is not available - use IM protocol)

Dose Method
Loading Dose Inj. MgSo4 (10 gm) 5 gm (2 amp in each buttock) Deep IM
4 ampoule (2.5 x 4=10gm)

Maintenance Dose Inj. MgSo4 (2.5 gm = 5 ml) 2.5 gm every 4 hours using
alternate buttock up to 24 hours Deep IM

Source: 1. WHO’s essential care practice guidelines for pregnancy and childbirth
2. Life Saving Skills Manual, Essential Obstetric and Newborn Care, RCOG
3. Fernando Aries, Practical Guide to High risk pregnancy , 3rd ed Elsevier 2008

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 Foot Note-1:
• Mild preeclampsia often has no symptoms.
• Mild preeclampsia may progress rapidly to severe preeclampsia.
• Oedema of the feet and lower extremities are not considered a reliable sign of preeclampsia.
• The risk of complications, including eclampsia, increases greatly in severe preeclampsia.
• A small proportion of women with eclampsia have normal blood pressure.
• Treat all women with convulsions as if they have eclampsia until another diagnosis is confirmed.
• Random urine sampling, such as the dipstick test for protein, is a useful screening tool.
• If dipsticks are not available, a sample of urine can be heated to boiling in a clean test tube. Add a drop of 2%
acetic acid to check for persistent precipitates that can be quantified as a percentage of protein to the volume of the
total sample.
• Only clean-catch mid-stream specimens should be used.
Foot Note-2:
• MgSO4 Loading Dose: MgSO4 20% solution (4 g IV over 5 minutes), MgSO4 50% solution (3 g deep IM
injection in each buttock).
• Maintenance Dose: Check& if urine output > 30 ml per hour, respiratory rate > 16, and patellar reflexes
present, then give MgSO4 2.5 gm 50% solution every 4 hours 1.M in alternate buttock for 24 hrs.
• MgSo4 toxicity --> RR < 16/min, urine output< 30 ml/hr., absent patellar reflex
¡ Omit next doses of MgSo4
¡ give Inj. calcium gluconate 1 gm (10 ml) slow IV
¡ Assist ventilation if needed
• If convulsion recur after 30 minutes of loading dose - add 2.5 gm of Inj. MgSo4 in 5 ml DW(20% solution)
push IV over 5 minutes
• If skilled provider to use IV/IM protocol is not available use IM protocol (give 10 gm IM loading dose MgSo4 5
gm in each buttock before referral) at peripheral facility / home before referral
• Diazepam therapy - If MgSo4 not available /contraindicated
• Loading dose - 10 mg IV slow over 2 min, if convulsion recur repeat 10 mg IV slowly:
• Maintenance dose: Inj. Diazepam 40 mg in 500 ml NS in IV drip. Rate adjusted so that patient remains
sedated but arousable. Do not use >100mg/24 hrs
• IV fluids to maintain urine output of 30 ml/hour. Use 1 liter normal saline over 6 hours initially and monitor
carefully for fluid overload.
• Bed side clotting test: Take 5ml blood in a test tube, keep it upright, turn it after 5 minutes to seeclot formation.
¡ If clotnot forms, turn every 1 minute. If fails to clot within 10 min - test +ve - coagulation failure.

Referral
Consider referral for tertiary level care of women who have:
¨ Oliguria that persists for 48 hours after delivery
¨ Coagulation failure (e.g. coagulopathy)
¨ Hemolysis, elevated liver enzymes and low platelets (HELLP syndrome)
¨ Persistent coma lasting more than 24 hours after convulsion

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 Plan for delivery

Gestational HTN Mild Preeclampsia Severe Preeclampsia Eclampsia

Plan of Delivery

At term (37 - At term (37 weeks) >34 <34 Deliver in 12

completed - Worsening maternal or fetal weeks weeks hours
weeks) condition
- Labour/rupture of membranes
Deliver
Expectant management
- Admit
- Steroids
Assess cervical status Contraindications to - MgSo4
expectant management - Antihypertensives
If Favorable induce with - Eclampsia - Maternal & fetal
ARM followed by - Non-reassuring fetal Monitoring
oxytocin status
If unfavorable ripen with - Pulmonary edema
PGs or Foleys - DIC
catheter/Caesarean - Acute renal failure
section - Abruption
- Uncontrollable severe
HTN

Deliver once maternal condition Additional complications:

is stabilized i.e after control of - Persistent symptoms Continue
YES NO
- HELLP syndrome expectant
hypertension & Convulsion
- IUGR management
- Worsening fetal status
Deliver after stabilization - Labour/Rupture of
membrane
Severe Oligohydramnios

ARM: Artificial rupture of membranes HELLP Syndrome: Hemolysis

PG: Prostaglandins EL: Elevated Liver enzymes
DIC: Disseminated Intravascular Coagulation LP: Low Platelet count
IUGR: Intrauterine Growth Retardation

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 Management Protocol for
Hypertensive Disorder in Pregnancy at Community level

Providers
• FWV
• FWA (CSBA)
• HA (CSBA)
• SACMO
• CHCP

Facility
• Settings where administration of full magnesium sulphate regimen is not possible
• Not ready to manage PE/Eclampsia patients
• Recommendation- use loading dose of magnesium sulphate followed by immediate transfer to CEmONC center
of severe PE and Eclampsia patient.

Classification of Hypertensive Disorder in Pregnancy

Four types
1. Pregnancy induced hypertension: Hypertension after 20 wks of gestation
2. Preeclampsia: Pregnancy induced hypertension with proteinuria
3. Severe preeclampsia: Presence of one or more danger sign with preeclampsia
4. Eclampsia: Preeclampsia with convulsion or coma

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 Symptoms and Signs according to classification of
hypertensive disorder in pregnancy

Clinical presentation of pregnancy induced hypertension

• Diastolic BP 90- • Diastolic BP 90- • Diastolic BP > 110 mmHg • Diastolic BP 90

109 mmHg on two 109 mmHg on two + mmHg or more and
occasions at least occasions at least 2 • Presence of albumin in urine • Convulsion /Coma
2 hrs apart hrs apart ( +/- ve)
• No Albumin in • Albumin in urine +
urine • No severe symptom • Any one or more danger
sign from below (+/- ve)
o Severe headache
o Blurring vision
o Epigastric pain
Hypertension Mild Pre-Eclampsia Or Eclampsia
in pregnancy / • Diastolic BP 90-109 mmHg
gestational HTN +
• Presence of Albumin in urine
+/- ve
+
• Any one or more danger sign from below
o Severe headache
o Blurring of vision
o Epigastric pain

Severe pre-eclampsia

• Remember, pregnancy induced hypertension may not produce any symptom, only high BP may be the sign
• Sometime albumin may not be present in urine

Diagnosis of hypertension in pregnancy & management at community level

As per WHO recommendation, by 8 standard ANC, hypertension in pregnancy can be detected. Take specific history with the aim to detect
hypertension in pregnancy in each ANC and PNC and even in intranatal period.
Ask or query the pregnant woman –
• Hypertension from before pregnancy or after pregnancy
• Any symptom from following –
- Severe headache
- Blurring of vision
- Epigastric pain, nausea, vomiting, generalized edema
• Measure BP 2 hourly in sitting position
• Check for albumin in urine

For diagnosis of Pregnancy induced hypertension, PE, Eclampsia

Ask the patient / family member/attendant who came with the patient about
• Last menstrual period of pregnant woman, duration of pregnancy, time place and birth attendant if she has immediate delivery
• Whether she was suffering from HTN before
• Whether the pregnant woman had headache, swelling of body, epigastric pain if any, for how long?
• Whether she had any P/V watery discharge or bleeding if any for how long
• Whether she has labour pain if any for how long?

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Assessment of Patient condition
Eclampsia is a very emergency condition, so, some management should be given side by side the examination of the patient.
• Watch for consciousness of patient. If the patient is unconscious kept her in the left lateral position with straight head to make the
airway open up (eclamptic position)
• To prevent tongue bite and to drain saliva through opening of mouth, put rolled scarf or cloth in between two gum or and teeth and
aside
• Be careful the patient should not be hurt or be fallen from bed.
• Observe patient is breathing and make sure that the airway is open and clean
• Check pulse and BP, examine the lower abdomen if the bladder is full or not
• Check per abdominally SFH, contraction of uterus lie and FHS
• If the patient has labour pain do pervaginal examination to assess the dilatation of cervix and delivery is imminent or not
• Check for postpartum haemorrhage and injury in the vagina if the patient come after delivery and take measures accordingly

Primary Management (Severe Preeclampsia and Eclampsia) – at community level

A. Antenatal
• Injection MgSo4 10 gm (20 ml) I/M, (5 gm (10 ml) I/M in each buttock)
• Immediately refer to comprehensive EmONC center /district hospital
B. Intranatal (imminent delivery, 1st stage of labour /2nd stage of labour)
• Inject Inj. MgSo4 loading dose 10 gm (20 ml) I/M, (5 gm (10 ml) I/M in each buttock)
• Conduct delivery
• AMTSL
o Inj. Oxytocin I/M stat / Tab. Misoprostol 2 tab per rectally
o Control cord traction
o Fundal massage
o Record BP hourly
o Refer the patient immediately to comprehensive EmONC Centre/district hospital
C. Postnatal :
• Inj. MgSo4 5 gm/ I/M in each buttock, total 10 gm (20 ml) I/M
• Refer immediately to comprehensive EmONC centre /district hospital

Management of Eclampsia
• The aim of management of eclampsia is to prevention of maternal and Foetal death by preventing respiratory distress and convulsion
• Keep the patient in left lateral position with head extended and at lower level to make the airway open up (eclamptic position)
• Introduce rolled cloth in between both gum and teeth and keep the airway open and clean
• Counsel the family members about the effects on mother and foetus
• Indwelling Foley’s catheterization to measure urine output (if possible)
• Inject loading dose of inj. MgSo4 5 gm in each buttock I/M (if respiration rate and urine output is normal (according to chart)
• Immediately counsel with referral centre and fill up the referral card
• Immediately refer the patient to nearby comprehensive EmONC centre by managing transport
• If delivery is imminent give inj. MgSo4 loading dose as above and prepare for conduction of delivery
• Active management of 3rd stage of labour
- Inj. Oxytocin I/M immediately /Tab. Misoprostol (2 tab) per rectally
- Control cord traction
- Fundal massage
• Inj. MgSo4 I/M stat if it occur after delivery, immediate care of newborn and refer immediately

IM protocol (Community level)

(If skill provider to give IV injection is not available - use IM protocol)

Dose Method
Loading Dose Inj. MgSo4 (10 gm) 5 gm (2 amp in each buttock) Deep IM
4 ampoule (2.5 x 4=10gm)

Maintenance Dose Inj. MgSo4 (2.5 gm = 5 ml) Deep IM 2.5 gm every 4 hourly using

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Job description for management of preeclampsia and eclampsia at community level

WHERE WHO WHAT SYMPTOMS AND DIAGNOSIS TO DO

SIGNS

At Home Health -Registration of the

Assistants(HA), pregnant women - Severe Headache
Family Welfare - Blurring Vision
Assistants(FWA), - Counseling about - Epigastric Pain
Community Skilled pre-eclampsia and -Measure BP(if
Birth Attendants eclampsia by using possible)
(CSBA) pictorial cards
- Blood pressure(BP)
has to be measured -Diastolic BP Pregnancy -Advise rest
in sitting position ≥90mmHg (on two induced - Explain danger signs
- If Diastolic BP is occasion) and Urine hypertension - Check BP and urine albumin
raised >90mmhg, albumin nil (PIH) again after 3 days
then repeat BP check -If diastolic BP remains ≥90mmHg
after 1 hr. refer her to doctor at Upazila
-Urine albumin should health complex for treatment of
be measured by Dip hypertension
stick
Diastolic BP 90- Mild -Immediately refer to
109 mmHg (on two Preeclampsia Comprehensive Emergency
occasion) and Urine Obstetric Care (CEmONC) or
albumin present but no District hospital
danger signs

Diastolic BP 90- Severe Start loading dose of magnesium

109 mmHg (on two Preeclampsia sulphate (MgSO4)
occasion) and Urine Refer to District hospital or
albumin present and Comprehensive Emergency
danger signs present Obstetric Care (CEmONC)

Diastolic BP ≥110 Severe Start loading dose of mgSO4

mmHg (on two Preeclampsia Refer to District hospital or
occasion) and Urine Comprehensive Emergency
albumin present Obstetric Care (CEmONC)

Diastolic BP ≥90mmHg Eclampsia Start loading dose of mgSO4

with convulsion Refer to District hospital or
Comprehensive Emergency
Obstetric Care (CEmONC)

At EPI Center Community Health - Counseling about

Care Provider pre-eclampsia and
(CHCP) at eclampsia by using
Community Clinic/ pictorial cards and
FWV at Satellite refer
clinic

At Community Health assistant Registration of the Severe Headache Pre-eclampsia - Arrange BP measurement at
Clinic (HA), pregnant women Blurring Vision (probable) sitting position by Skilled birth
Family welfare Epigastric Pain attendant(CSBA) or Family welfare
assistant(FWA), Counselling about Measure BP if possible visitor(FWV)
Community Skilled preeclampsia and
Birth Attendants eclampsia by using - Communicate with the CSBA or
(CSBA), pictorial Cards FWV through cell phone
Community Health
Care Provider Classification of the - Send the pregnant woman to
(CHCP) disease according Union Health and Family Welfare
to Danger Sign Centre
verification

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Job description for management of preeclampsia and eclampsia at UH & FWC level

WHERE WHO WHAT SYMPTOMS AND DIAGNOSIS TO DO

SIGNS

Diastolic BP Pregnancy induced Advise rest

Family Welfare Blood ≥90mmHg (on hypertension (PIH) Explain danger signs
Visitor (FWV), pressure(BP) has two occasion) and Check BP and urine
Sub-Assistant to be measured in Urine albumin nil albumin again after 3
community sitting position days
medical If Diastolic BP is If diastolic BP remains
Union Health officer(SACMO) raised >90mmhg, ≥90mmHg refer her to
&Family then repeat BP doctor at Upazila health
welfare Centre Doctor if posted check after 1 hr. complex for treatment of
(UH&FWC) (special case) rest hypertension
Urine albumin
should be Diastolic BP 90- Mild Pre-eclampsia Immediately refer
measured by urine 109 mmHg (on to Comprehensive
stick two occasion) and Emergency Obstetric
Urine albumin & Newborn Care
present but no (CEmONC) or District
danger signs hospital

Diastolic BP 90- Severe Pre-eclampsia Start loading dose of

109mmHg (on magnesium sulphate
two occasion) and (mgSO4)
Urine albumin Refer to District hospital
Satellite clinic present and danger or Comprehensive
signs Emergency Obstetric
& Newborn Care
(CEmONC)

Diastolic BP ≥110 Severe Pre-eclampsia Start loading dose of

mmHg (on two mgSO4
occasion) and Refer to District hospital
Urine albumin or Comprehensive
present Emergency Obstetric&
Newborn Care
(CEmONC)

Diastolic BP Eclampsia Start loading dose of

≥90mmHg with mgSO4
convulsion Refer to District hospital
or Comprehensive
Emergency Obstetric
& Newborn Care
(CEmONC)

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Protocol for management of pre-eclampsia and eclampsia at Facility level
(at District hospitals or Comprehensive Emergency Obstetric care Centre)

WHERE WHO HOW WHAT OBSERVATION DIAGNOSIS TO DO

Doctor ¨ Measure BP in - Diastolic BP Hypertension -Advise rest

sitting position ≥90mmHg (on two - Explain danger signs
¨ If diastolic occasion) and Urine - Check BP and urine albumin
BP≥90mmhg then albumin nil again after 3 days
repeat BP check after
-If diastolic BP remains
1 hr.
¨ Check urine
≥100mmhg add
Upazila Health albumin antihypertensive.
Complex (at For example: labetalol, methyl
Comprehensive -encourage routine dopa, nifedipine, hydralazine
Obstetric care antenatal check ups Drugs which are
Centre or Basic -advise skilled contraindicated in pregnancy:
Obstetric care obstetric care/hospital ACE inhibitor, beta blocker,
Centre) obstetric care diuretics (frusemide)
-to prevent PIH/pre-
eclampsia/eclampsia Diastolic BP 90- Mild Preeclampsia -Immediately refer to
prescribe calcium 110 mmHg (on two Comprehensive Emergency
500mg 2 tablet daily occasion) and Urine Obstetric & Newborn Care
to all pregnant woman
albumin present but (CEmONC) or District hospital
during their antenatal/
no danger signs
prenatal visits from
12 weeks pregnancy Diastolic BP 90- Severe -Start loading dose of injection
onwards
<110mmHg (on two Preeclampsia magnesium sulphate
- Advise birth spacing
of 2-5 years to occasion) and Urine -Refer to District hospital or
women who has child albumin present and Comprehensive Emergency
and encourage to use danger signs Obstetric & Newborn care
Long acting reversible (CEmONC)
contraceptives(LARC)
-Diastolic BP ≥110 Severe Pre- -Start loading dose of Inj.
mmHg and Urine eclampsia MgSO4
albumin present -Refer to District hospital or
Comprehensive Emergency
Obstetric & Newborn Care
(CEmONC)

-Diastolic BP Eclampsia -Start loading dose of Inj.

≥90mmHg with MgSO4
convulsion -Refer to District hospital or
Comprehensive Emergency
Obstetric & Newborn Care
(CEmONC)

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Protocol for management of pre-eclampsia and eclampsia at Facility level
(at District hospitals or Comprehensive Emergency Obstetric care Centre)

Patients with severe preeclampsia/eclampsia before arriving at comprehensive obstetric care centre:
• If loading dose of injection magnesium sulphate is pending treat according to Protocol of severe pre-
eclampsia and eclampsia [standard management protocol on Emergency Obstetric& Newborn Care
(EmONC)]
• If loading dose of injection magnesium sulphate given continue with magnesium sulphate. Maintenance
Therapy as per mentioned protocol.

If patient convulse after giving loading dose during continuation of Maintenance Therapy; then:

A. If convulsion occurs within 30 minutes of giving injection Magnesium sulphate- keep in observation
B. If convulsion occurs after 30 minutes of giving injection Magnesium sulphate –give injection MgSO4 2.5 gm (5ml)
diluted with 5 ml distilled water

or normal saline slow IV.

-Encourage routine antenatal and postnatal care

• Measure BP in sitting position
• If diastolic BP≥90mmhg then repeat BP check after 1 hr.
• Check urine albumin

- Advise skilled obstetric care/hospital obstetric care

-To prevent PIH/Pre-eclampsia/eclampsia prescribe calcium 500mg 2 tablet daily to all pregnant woman during their
antenatal/prenatal visits from 12 weeks pregnancy onwards
- Advise birth spacing of 2-5 yrs. to women who has child and encourage to use Long acting reversible contraceptives
(LARC)

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24: Protocol for Gestational Diabetes Mellitus

Hyperglycaemia first detected at any time during pregnancy should be classified as either gestational diabetes mellitus
(GDM) or diabetes mellitus in pregnancy (DIP), according to WHO criteria.

Diagnosis of GDM
1. Diagnosis of GDM (at any time in pregnancy if one or more of the following criteria are met):
 Fasting plasma glucose : 5.1-6.9 mmol/l (92 -125 mg/dl)
 1-hour plasma glucose : ≥ 10.0 mmol/l (180 mg/dl)
 2-hour plasma glucose : 8.5-11.0 mmol/l (153 -199 mg/dl)

2. Diabetes in pregnancy (DIP) if one or more of the following criteria are met:
 Fasting plasma glucose : ≥ 7.0 mmol/l (126 mg/ dl)
 2-hour plasma glucose : ≥ 11.1 mmol/l (200 mg/dl)
 Random plasma glucose: ≥ 11.1 mmol/l (200 mg/ dl) in the presence of diabetes symptoms.

Screening of GDM
1. All pregnant women at booking visit and rescreen between 24 and 28 wks( if initial OGTT is normal)
2. Those who are high risk for GDM, rescreen again between 34 and 36 wks ((even if 2nd OGTT is normal)

Risk factors include:

• Previous diagnosis of GDM
• Prediabetes
• Member of a high-risk population
• Age ≥35 years
• BMI ≥23 kg/m2(based upon ethinicity)
• PCOS, acanthosisnigricans
• Corticosteroid use
• History of macrosomic infant
• Current fetal macrosomia or polyhydramnios
Management
Key Components

 Lifestyle Management
 Medical Nutrition Therapy (MNT)
 Pharmacologic therapy

1. Life Style Management :Moderate exercise (at least 30 minutes/day) aerobic activities: walking 20-30min,3-4
times/wk.

2. Medical Nutrition Therapy (MNT): By a registered dietitian if available

• Diet Plan: 3 meals and 3 snacks ( midmorning, afternoon and prebed)
• Calorie needed
- Normal: BMI (18.5–22.9 kg/m2): 30–38 kcal/kg/day
- Overweight: BMI (23-27.4 kg/m2): 25 -30 kcal/kg/day
- Obese: BMI ( >27.5kg/m2): 30-33% calorie restriction
- Underweight BMI: ( <18.5kg/m2) : 35- 40kcal/kg /day

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 • Calorie Distribution :
- At breakfast 10-15%
- At lunch 20-30%
- At dinner 30-40%
- Snacks 0-10%
• Composition: Carbohydrate- 40-50% complex, Protein 20%, Fat 30-40%(10% saturated)
3. Pharmacotherapy: If women with GDM do not achieve glycemic targets within 2 weeks from nutritional
therapy alone, insulin therapy should be initiated.

Starting insulin dose

0.8U/kg/day in 1st trimester
1U/kg /day in 2nd trimester
1.2U/kg/day in 3rd trimester
Total daily insulin requirement=

2/3rd as NPH (intermediate)

Give 2/3rd of total dose in fasting state

1/3rd as regular insulin
or Lispro

½ regular or insulin
lispro at dinner
& 1/3 at night
rd

½ NPH at bed time

Or
Give Regular Insulin with starting dose as Inj Actrapid/Maxsulin R/HumilinR ® 4+4+4 (±2) Subcutaneously ½ hr.
before meal
Or
Inj Intermediate insulin+ Regular insulin (Mixtard 70/30) ®8+0+4 (±2) Subcutaneously ½ hr. before meal and then
treat the dose as per glucose level

Glycemic control
i) Glycemic target :
 Preprandial < 5.3 mmol/L
 1-hour postprandial BG< 7.8 mmol/L; or
 2 hours post-prandial BG < 6.7 mmol/L
ii) Self-monitoring of blood glucose (SMBG) : Teach and ask the patient to monitor blood glucose at least 4
times/day (i.e. fasting & 2 hour after each meal i.e. breakfast, lunch, dinner)

Special points to remember:

1 unit of rapid acting insulin lowers blood glucose 30mg/dl
 10gm of –CHO increases blood glucose 30mg/dl
 1unit of rapid acting insulin will cover intake of 10gm of -CHO

Special points for antenatal care

• Well controlled GDM without any complications : routine antenatal care
• Uncontrolled GDM +/or any complication : every 2 weekly in 2nd trimester, every wk. in 3rd trimester
• Fetal anomaly scan : at 18 -22wks
• Fetal echocardiography: at 24 – 26 wks

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 • Woman is counselled to keep record of daily fetal movement counts because of unexplained IUD
• Well controlled GDM with MNT, can deliver at term , preferably with neonatal care facilities
• Woman on insulin should be referred at higher centre for monitoring during labour, infusion pump for insulin therapy
& for neonatal management
• Steroid : who need early delivery between 24 to 34 wks gestation, and refer to higher centre

Care during Labour

• Induction of labour - at early morning

• BG monitoring
If on MNT: 4 to 6hrly
If on insulin: Hourly

• Maintain glycaemic control between 4 - 7mmol/l

• If well-controlled , insulin may not be needed
• Those on insulin:
i) 5% dextrose solution with a fixed dose of insulin in it or a simultaneous infusion of insulin through insulin pump can be
started with glucose infusion and then titrated to maintain the glycemic target.
ii) 6-8 units of conventional regular insulin or analogue like lispro or aspart be added to 500 ml of 5% DNS with monitoring
of the blood glucose every 1-2h and then titrate the insulin infusion rate

Labour Analgesia: Epidural analgesia (If available)

Care during Caesarean section (CS)

• Plan caesarean section(elective) at early morning.
• Give usual night dose of insulin.
• Morning dose to be withheld and patient be kept nothing by mouth.
• Monitor blood glucose hourly.
• If require corrective dose of short acting insulin can be given subcutaneously.
• Hyperglycemia should be avoided during the surgery to reduce the risk of neonatal hypoglycemia.
• Optimization of glycemic control is vital during perioperative and postoperative period.

Neonatal Care
• Ensure presence of neonatologist/paeditrician (if available)
• Feeding should be started as soon as possible after birth, preferably within 30 minutes and then continue every 2-3
hours until feeding maintains pre-feed capillary plasma glucose levels at a minimum of 2.0 mmol/litre
• If values are < 2.0 mmol/L on 2 consecutive times, or there are abnormal clinical signs or if the baby does not feed
orally effectively, additional measures to be taken such as tube feeding or intravenous dextrose.

Postnatal Care: Women with gestational diabetes mellitus should go for test for persistent diabetes at 4–12 weeks’
postpartum, using the oral glucose tolerance test

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Flowchart for Management for Diabetes in Pregnancy

Diabetes pregnancy pathway

Specialist services for diabetes in pregnancy

Weight and lifestyle advice

Ultrasound scan at the time of diagnosis

Glucose targets fasting ≤ 5.3mmol/L; 1-hour post-prandial ≤7.8mmol/L;

2-hour post
- prandial ≤6.7mmol/L

insulin

36 to 37 weeks ultrasound scan and plan timing of delivery

Normal growth and no Comorbities

comorbidity present/Preexisting DM
P{pPreexisting

Plan delivery at 40 weeks or

Glucose levels not in target range or
on insulin

Delivery 38 to 39 weeks

References:
1. Diagnostic criteria and classification of hyperglycaemia first detected in pregnancy. Geneva: World Health Organization; 2013 (WHO/NMH/MND/13.2; http://
www.who.int/diabetes/publications/Hyperglycaemia_In_ Pregnancy/en/, accessed 29 September 2016)
2. ADA. Classification and Diagnosis of Diabetes: Standards of Medical Care in Diabetesd2018. American Diabetes Association. 2018 Supplement 1, January
2018;41.
3. Diabetes in pregnancy: management from preconception to the postnatal period. NICE guideline. 2015 25 February 2015.
4. Metzger BE, Buchanan TA, Coustan DR, de Leiva A, Dunger DB, Hadden DR, et al. Summary and recommendations of the Fifth International Workshop-
Conference on Gestational Diabetes Mellitus. Diabetes Care. 2007 Jul;30 Suppl 2:S251-60. PubMed PMID: 17596481. Epub 2008/02/27. eng.
5. O’Dea A, Tierney M, McGuire BE, Newell J, Glynn LG, Gibson I, et al. Can the Onset of Type 2 Diabetes Be Delayed by a Group-Based Lifestyle Intervention
in Women with Prediabetes following Gestational Diabetes Mellitus (GDM)? Findings from a Randomized Control Mixed Methods Trial. Journal of diabetes
research. 2015,Life style Mx; 2015:798460. PubMed PMID: 26347894. Epub 09/09. eng.
6. GDM SAFES Recommendations and action plan, 2017
7. WHO guidelines for management of common maternal conditions ,Pocket book for Hospital care of mothers, 2017ed.p-141

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25: Protocol of Jaundice in Pregnancy

Definition Yellow discoloration of the skin, mucous membranes, and the sclera of the eyes caused by the increased
amounts of bilirubin in the blood. Jaundice detected clinically at bilirubin concentration of 2 mg% or more
(normal 0.2-0.8 mg%).

Causes of Jaundice in pregnancy

Jaundice unique to pregnancy Jaundice due to inter-current illness
• Obstetric cholestasis Viral hepatitis
• Acute fatty liver Drug induced – INH, Phenothiazines
• Severe preeclampsia & eclampsia Cholelithiasis
• HELLP syndrome Haemolytic jaundice
• Severe hyperemesis gravidarum Auto immune hepatitis
• Endotoxic shock CLD
Malaria
Hepatic neoplasm
Pancreatitis

Clinical presentation
• Yellow coloration of the eyes and skin
• Itching all over the body
• Dark colored urine
• Pale stools
• Weakness
• Loss of appetite
• Headache
• Nausea and vomiting
• Fever
• Hepatomegaly
• Tremor of the hand
• Bleeding manifestation
¡ Per vaginal bleeding
¡ Hematuria
¡ Gum bleeding

• Semiconscious
• Unconscious

Abdominal Examination
• Liver slightly enlarged and tender – viral hepatitis
• Firm liver edge – Cirrhosis
• Liver enlarged and smooth – post hepatic obstructive jaundice
• Splenomegaly – Cirrhosis
• Pancreatic tumor may be palpable

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Investigations:
• CBC-including reticulocyte count and blood smear to detect haemolysis
• Serum bilirubin
• Liver enzymes
¡ Serum alanine transaminase (ALT/SGPT)
¡ Serum aspartate transaminase (AST/SGOT)
¡ Alkaline phosphatase
¡ Fasting bile acid
¡ Gamma glutamyltransferase (GCT)
¡ Lactate dehydrogenase (LDH)

Interpretation
 From ALT (SGPT) level different liver diseases can be suspected e.g.
 > 1000 IU/L: acute parenchymal disease
 > 400 IU/L: Viral hepatitis (diffuse acute hepatocellular damage)
 150 - 400 IU/L: chronic active hepatitis, or viral or drug induced hepatitis
 <100 IU/L: obstructive jaundice
 ALT (SGPT) raised more than AST(SGOT) in acute hepatitis and in extrahepatic obstruction
 AST (SGT) raised more than ALT(SGPT) in cirrhosis, intrahepatic nepolasia, hemolytic jaundice and alcoholic
hepatitis
 Alkaline phosphatase, Fasting bile acid, GCT are raised in intrahepatic cholestasis
 Alkaline phosphatase is raised in gall stone causing bile duct obstruction
 LDH a marker of hemolysis raised in HELLP syndrome
• Viral markers i.e. Antibodies (IgM & IgG) against hepatitis A, C, D, and E
• For hepatitis B virus
 HBsAg (Surface antigen)
 HBeAg (E antigen)
 (Core antibody)
 HBsAb (Surface antibody)
• Blood sugar, Fasting and 2 hours after 75 gm glucose
• Coagulation profile
¡ Prothrombin time (PT)
¡ Fibrinogen level
¡ Fibrin degradation product (FDP)
¡ D-Dimer
• Ultrasonography of Hepatobiliary system and pregnancy profile
Overview of different jaundice including management
1. Jaundice unique to pregnancy
a) Obstetric cholestasis/intrahepatic cholestasis
Clinical Features
¡ Typically present at third trimester
¡ Intense Pruritis, starts from palms and soles, generalized and often worse at night
¡ Jaundice uncommon, if present; arises 2-4 weeks after the onset of pruritus
¡ May be associated with other signs of cholestasis – e. g. pale stool, dark urine

Laboratory findings
¡ ALT: raised 2- 20 fold
¡ Fasting serum bile acid (key diagnostic): >10 micro mol/L
¡ Alkaline phosphatase: raised up to 4 fold
¡ Gama Glutamine transferase: > 40U/L

Fetal risk
¡ Spontaneous preterm labour
¡ Increased risk of fetal distress –more when fasting bile acid is > 40 micro mol/ L
¡ Fetal asphyxia
¡ Intra uterine death (IUD)

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Monitoring
¡ No current guidelines regarding specific fetal monitoring that might reduce the risks , however maintaining kick
count and regular CTG can be done
LFTs including PT to be done weekly, if they return to normal or increase (into the 100s), the diagnosis needs to
¡
be revised
Treatment
¡ General care of the mother
 Adequate rest
 Low fat diet
¡ Specific treatment
 Topical emollients (aqueous cream with menthol)
 Ursodeoxycholic acid (UDCA) 150-300 mg 2-3 times a day
 Inj. vitamin K- 10 mg I/V daily for 5days
¡ Delivery - Induction of labour after 37 weeks because of increased risk of perinatal mortality and maternal
morbidity
¡ Continuous fetal monitoring during labour
¡ Inj. Vitamin K: IM for neonate
¡ Postnatal: Check LFTs on the day of discharge. If not normalize recheck at approx. day 14
¡ Recurrence risk: 90% in subsequent pregnancies
b) Acute fatty liver of pregnancy is a rare condition characterized by acute liver failure
Risk factors:
• First pregnancy
• Preeclampsia
• Twin pregnancies
• Male fetuses
Pathology: Deficiency of LCHAD (3-hydroxyacyl-CoA dehydrogenase) in the foetus leads to accumulation of medium
and long chain fatty acids. These unmetabolized fatty acids will re-enter the maternal circulation through the placenta, and
overwhelm the beta-oxidation enzymes of the mother. LCHAD deficiency is autosomal recessive in inheritance and mothers
are often found to be heterozygous for the affected mutation.
Clinical Presentation: Usually presents acutely at about 35 weeks of gestation but can occur much earlier and may
immediately after delivery with
• Nausea, vomiting
• Abdominal pain
• Fevers, headache
• Polydipsia and polyuria
• Pruritus
• Jaundice
• Fulminant liver failure may follow
Laboratory Findings
• Leukocytosis , often with neutrophilia and thrombocytopenia
• Liver transaminases are moderately high (3 to 10 times)
• Raised serum bilirubin (> 14 micro mol/L)
• Coagulopathy (prolongation of PT, a PTT, and decreased fibrinogen levels)
• Hypoglycemia (< 4 mmol/L)
• Renal impairment (creatinine > 150 micro mol/L)
• Elevated ammonia (> 47 micro mol/L)
• Elevated urate (> 340 micro mol/L)
• Ascites or bright liver on ultrasound scan
• Micro vascular steatosis on liver biopsy ,usually not done
• CT/MRI scanning may show reduced attenuation in the liver
**One of the keys to diagnosis of AFLP is rapid deterioration of liver function.
Management:
• Admission in ICU

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 • Multidisciplinary approach (Fetomaternal and hepatology specialist)
• Maternal resuscitation by correction of
¡ Hypoglycemia
¡ Fluid balance
¡ Coagulapathy

• Intensive fetal monitoring

• Urgent delivery. Vaginal delivery is preferable.
• Remain vigilant for PPH
Complications/ outcome:
• AFLP is a life-threatening condition with a reported 1.8% maternal and 23% fetal mortality rate
• Serious complications include
¡ DIC
¡ Hepatic encephalopathy
¡ Acute Kidney injury
¡ Pancreatitis
¡ Hypoglycemia

• Recurrence may be as high as 10-20%

c) HELLP Syndrome (Hemolysis, Elevated Liver enzymes and Low Platelets)
About70% of cases occur during the last trimester of pregnancy.
Clinical Presentation:
• Right upper quadrant abdominal pain, nausea, vomiting, malaise, and edema with significant weight gain
Laboratory findings include
• Bilirubin: usually < 5 mg/dL
• Lactate dehydrogenase (LDH): > 600 IU/L
• Moderately elevated aspartate aminotransferase (AST) and ALT levels (200 IU/L to 700 IU/L)
• Thrombocytopenia (< 100,000/mm3)
• PT and a PTT may be prolonged
• DIC may be present
Management:
• Multidisciplinary approach involving Obstetrician, Internist, and Neonatologist.
• Maternal resuscitation by correction of
¡ Control of hypertension
¡ Fluid and electrolytes balance
¡ Prophylaxis for convulsion with MgSO

• Intensive fetal monitoring

• Steroid ( between 24 wk. - 34 wk.)
• Timely delivery
• Remain vigilant for PPH
• Close monitoring up to 48 h postpartum.
Complications/Outcome:
• Increased maternal mortality (1%) and perinatal mortality (7%-22%)
• Abruption of placenta
• Acute renal failure
• Adult respiratory distress syndrome
• Pulmonary edema
• Stroke
• Liver failure
• Hepatic infarction
2. Jaundice due to inter-current illness
Viral Hepatitis: Most common cause of jaundice in pregnancy.
The course of most viral hepatitis infections is unaltered by pregnancy except hepatitis E having fatality rate 10-20% in
pregnancy

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Hepatitis A
• Management and prognosis is similar to non-pregnant women.
• Isolation
• Pregnant women exposed to the virus can be given immune globulin within two weeks of exposure, together with
vaccine.
• If the baby isborn within 2 weeks of acute maternal illness, neonate should receive immune globulin.
Hepatitis B
Can occur in acute, subclinical or chronic form.
• Presence of HBeAg is associated with very high risk of neonatal infection
• Without treatment in HBeAg positive mothers, 90% cases and in negative mothers , 10% cases of newborn
develop hepatitis B virus infection.
• Before initiating breast feeding, newborn should receive hepatitis B immune globulin and also vaccine (10µgm) at
birth, and complete the vaccine schedule . This will reduces vertical transmission to < 3%.
• Antivirals to be given ( with consultation with Hepatologist or refer) to mothers who are HBeAg positive and having
HBV DNA > 109 copies.
Hepatitis E
Hepatitis E virus infection occurs in non-industrialized nations, usually as an epidemic disease during the monsoon
season.
Hepatitis E Infection in third trimester is a cause of fulminant hepatic failure and has a mortality rate of up to 20%.
• Spread by feco - oral route.
• May need ICU supports if fulminant hepatic failure develops
• Associated with increased risk of abortion and intrauterine fetal death
• Maternal fetal transmission results in symptomatic neonatal hepatitis.
• No known therapy to prevent vertical transmission
Management
• Bed rest
• Low fat intake
• Maintain adequate protein and energy intake
• Intraveneous hydration: if nausea, vomiting or anorexia
• All hepatotoxic agents should be avoided
• Inj Vit K: 10mg IM for 3 to 5 days
• Laxative: Lactulose 40 -120ml daily
• Gut sterilization
- Neomycin 550mg 12 hourly at least for 2 weeks or
- Cap. Amoxycillin 500mg 8hourly +
- Tab. Metronidazol 400mg 8hurly
• Antenatal fetal assessment should be instituted in 3rd trimester
• Fresh Frozen Plasma : Indication of use
- INR >1.5
- PT > 1.5 times normal
- APTT > 2 times normal
Dose: 10-15ml/Kg body wt and transfuse within 4 hour.
For a woman of 60 kg 3-5 unit FFP have to be given
Follow up: daily with PT which begins to rise after 8 hours of plasma transfusion.

References:
1. Williamson C and Girling J. Hepatic and Gastrointestinal Disease. In High Risk Pregnancy: management Options, 4th edition; James D,
Steer PJ, Weiner CP, Gonik B, Crowther CA, and Robson SC editors. Publisher: Elsevier Inc. Saunders, Missouri. 2011; 839- 860.
2. Obstetric Cholestasis; Royal College of Obstetricians and Gynaecologists (May 2011)
3. Newsome PN, Cramb R, Davison SM, Dillon JF, Foulerton M, Godfrey EM, et al. Guidelines on the management of abnormal liver blood
tests Downloaded from http://gut.bmj.com/ on May 2018 - Published by group.bmj.com
4. Henderson Roger, Health article download from http://patient. Info/ doctor/ jaundice-pro

102 STANDARD CLINICAL MANAGEMENT PROTOCOLS AND FLOWCHARTS ON

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 Flow chart for management of jaundice in pregnancy

Evaluate the patient from history and clinical examination

Send all laboratory investigations to confirm diagnosis and assessment of the severity of the condition

Proceed with multidisciplinary approach

Consult with Hepatologist, Internist, and Neonatologist

Symptomatic & supportive management

Adequate rest
Nutrition: Diet rich in carbohydrate and adequate protein and low fat
Drugs: Neomycin, Lactulose, and Vitamin K
Avoid sedatives, narcotics
Treatment of complications

Specific Management according to cause

Termination of pregnancy

Jaundice unique to pregnancy Jaundice due to inter-current illness

No need for deliberate termination

Obstetric cholestasis Others

Termination at 37 weeks Terminate as soon as possible

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26: Anaemia in pregnancy

Iron Deficiency Anemia

Anaemia is defined as Hb<11g/dl (110g/L) in the first and third trimester <10.5g/d in the second trimester and <10g/dl
(100g/L) in the postpartum period(WHO).

Classification
Mild anemia: 10-10.9g/dl
Moderate anemia: 7 – 10g/dl
Severe anemia: 4 – 6.9g/dl
Very severe < 4g/dl

Treatment
General Treatment:
Diet: Balance diet rich in protein, iron and vitamins
Identify and eradicate if any sustained infection.
Effective therapy to cure the cause of anaemia.
Specific Treatment: The BNF recommends between 100-200mg of elemental iron per day until Hb-conc rises to normal.
Thereafter standard daily antenatal iron dose to prevent recurrence of anemia.
Note: Always exclude Haemoglobinopathies (by Hb Electrophoresis & S. Ferritin) if there is moderate to severe
anemia &/or MCV < 77 fl.
Do not give Iron, if Ferritin level is >150µgm/L

Iron Therapy: Oral and Parenteral therapy.

Choice of therapy depends on – Severity of anaemia, duration of pregnancy and associated complicating factors.
Oral iron should be taken on empty stomach 1 hr. before meal with a source of Vitamin C like orange juice. Other
medications or antacid should not be taken at the same time.
Ferrous sulphate: 200mg contains 60 mg of elemental iron. The initial dose is one tablet to be given thrice daily.
Thereafter a maintenance dose of one tablet daily. Iron therapy response is evidenced by –
Sense of well being, increased appetite.
Increased reticulocyte count within 7-10 days.
Increase in Hb level about 0.7gm/100ml per week.
N.B: If taken correctly will give a rise in Hb of 2mg/dl every 3wks
Available form in Bangladesh
Carbonyl Iron + Folic acid + Zinc

Parenteral Iron Therapy

Indication
• Absolute non-compliance with oral iron,
• intolerance to oral iron or proven malabsorption
• If rapid replacement is required, such as patients at risk of haemorrhage approaching their due date.
• Serum ferritin should always be confirmed prior to giving perenteral iron except where it is being used in the
immediate postpartum period following a massive postpartum haemorrhage.

Protocol for the use (example)

Iron - carboxymaltose has 50mg/ml of elemental iron.
• Administer by slow iv injection or infusion with no need for a test dose
• Should be avoided in the first trimester.

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 • Small risk of anaphylactoid reaction.
• It is suitable for administration in OPD and does not require any monitoring
• Oral iron should be avoided for 5 days after the administration of Ferinject.
• A follow up CBC should be performed at 2-3 weeks

Contraindications for the use of parenteral iron

First Trimester:
• Known hypersensitivity
• Anaemia not attributed to iron deficiency.
• Evidence of iron overload or disturbances in utilisation of iron.
Warnings and precautions:
Risk/benefits need to be considered if liver dysfunction, acute/chronic infection, atopic conditions.
Should be stopped if
• paravenous leakage lead to irritation and discolouration.
• anyanaphylactoid reaction, signs of allergic reaction or intolerance.
The dose is calculated on the pre-pregnancy/booking weight aiming for a target Hb of 11g/dl.
Table

Hb (g/dl) Weight 35kg Weight ≥

-<70kg 70kg

<10 1500mg 2000mg

≥10 1000mg 1500mg

Dilution plan carboxymaltose for IV drip infusion

Ferinject Iron Maximum amount of Minimum

sterile 0.9% sodium administration
chloride time

2-4ml 100-200mg 50ml -

>2-10ml >200-500mg 100ml 6min

>10-20ml >500-1000mg 250ml 15min

Indication of Blood Transfusion

• Haemoglobin 6.0 g/dl or below and gestational age is >36 weeks
• Haemoglobin between 6- 8 gm/dl and in the presence of the following conditions:
- Established or incipient cardiac failure or clinical evidence of hypoxia
- Pneumonia or any other serious bacterial infection
- Malaria
- Pre-existing heart disease, not causally related to the anaemia

Advice for Hospital delivery If Hb <10.5g/dl .

Women with Hb<10g/dl in postpartum period should be given 100-200mg elemental iron for 3 months. Once Hb is in the
normal range, supplementation should continue for 3 months

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Flow chart for the treatment of anaemia
Please note-the following should be used in conjunction with the full guideline and each case Individualized

1st trimester 2nd trimester Postpartum Iron deficiency

Hb<11g/dl Hb<10.5gdl Hb<10g/dl alone

Oral iron and arrange F/U CBC

(ferrous sulphate 200mg BD/TDS and folic acid 400mcg) 65mg elemental
iron OD
e.g. FeSO4
200mg OD
F/U CBC at 2-3 weeks

Improvement in Hb, Advise If no significant change

continuation until 3 months check Ferritin
after Hb within normal range.
Consider the need for a rpt
CBC and provide request
form

- Severe anaemia Ferritin

- Need for rapid <30µg/L If Ferritin level high exclude
replacement hemoglobinopathies
- Intolerance to oral iron
- Malabsorption

Parenteral Iron
- Provide patient information and check for any contraindication
- Calculate dose of ferinject
Anaemia following PPH - Full set of observation: (P.BP. T and RR), wait 30 minutes after infusion
where oral iron is considered before allowing discharge.
insufficient or inappropriate. - Arrange next dose if required
- Provide form for CBC check after 2-3 weeks
- Avoid oral iron supplementation for 5 days after infusion
- Advise patient to continue oral iron (if tolerated) for 3 month: after Hb in the
normal range.

References:
1. WHO e-library of evidence for Nutrition Actions (eLENA), Daily iron and folic acid supplementation during pregnancy.
2. Anemia in pregnancy, Antenatal Guidelines Plymouth Hospitals, NHS Trust
3. WHO guidelines for management of common maternal conditions ,Pocket book for Hospital care of mothers, 2017ed.p-135

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27: Intra Uterine Growth Restriction (IUGR)/Fetal
Growth Restriction (FGR)
Definition: IUGR/FGR is said to be present when Estimated Foetal Weight (EFW) is below 10th percentile of the average
for gestational age due to pathologic restriction of growth.

Screening:
A. Primary level care
History - Identify maternal, fetal, and placental risk factors
Establish dates by last menstrual period and first trimester ultrasound
Physical: SFH measurement
B. Secondary/Tertiary level care :In addition to above, consider following Investigations
 biochemical screening tests for Trisomy 21
 first trimester ultrasound for dating and nuchal translucency
 uterine artery Doppler at 19 to 23 weeks
 if SFH (in centimeters) is less than gestational age (in weeks) by > 3, arrange ultrasound for EFW, Amniotic Fluid
Volume (AFV) or Ductus Venosus flow, biophysical profile, and/or umbilical Doppler studies.

Diagnosis of intrauterine growth restriction

EFW or AC < 10th percentile

Screening of IUGR:

Booking Assessment
(first trimester)

Minor risk factors Reassess at 20

weeks
Maternal age≥ 35 years

Nulliparity

BMI<20
3 or more By SFH
BMI 25−34.9 risk factor

Smoker 1-10 cigarettes /day

Serial assessment
Previous pre-eclampsia of fetal size and
USG to assess umbilical artery
Pregnancy interval < 6 months AFV, EFW Doppler from 26-
28 weeks
If Abnormal
Major risk factors

Maternal age>40 years

Smoker ≥ 11cigarettes per day Uterine artery

Doppler at
Daily vigorous exercise 19-23weeks

Previous IUGR/stillbirth

Chronic hypertension
One risk factor
Diabetes with vascular disease

Renal impairment

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 Management of Intrauterine Growth Restriction

General management
 Encourage patient to quit smoking if smoker
 Consider adding low-dose aspirin early in pregnancy before 14 weeks if previous H/O IUGR
 Rest
 Improve Nutrition
 Treatment of underlying pathology (preeclampsia, DM)
 Consider maternal-fetal medicine and neonatologist consultation
 Consider in utero referral to tertiary centr e
 Consider Timely delivery before fetal demise or damage

Timing and Mode of Delivery

A. When Umbilical Artery End Diastolic Flow (UmA EDF) is present , delay delivery until 37 weeks , provided
other surveillance are normal

B. When Umbilical Artery End Diastolic Flow (UmA EDF) is absent or reversed

- consider admission

- close Foetal monitoring

- if other surveillance results (BPP, Venous Doppler) are abnormal,

delivery is indicated

C. When Umbilical Artery End Diastolic Flow (UmA EDF) is absent or reversed , but gestational age is > 34
weeks -delivery may be considered even if other results are normal

D. When Umbilical Artery End Diastolic Flow (UmA EDF) is absent or reversed but other results are normal,
options include daily CTG/BPP &/or Venous Doppler and

- Consider Delivery before 34 weeks if

 CTG is pathological i.e. decelerations with reduced variability
 Reversed Doppler velocities in ductus venosus or
 There are umbilical vein pulsations
In this situation Delivery is likely to be by LSCS

E. In addition delivery is indicated if:

- Results of fetal testing are grossly abnormal

- Foetal lung maturity is documented
- Foetal distress
- Maternal disease possess serious risk to the foetus

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APPENDIX: Flow chart of Management of IUGR

SFH: <3weeks from gestational age High risk of SGA fetus/neonate

Based on history, biochemistry or
uterine artery Doppler

Fetal biometry
Single AC or EFW<10th customized centile
Serial measurements indicative of FGR

UA Doppler
Refer
for fetal
Normal UA Doppler Pl or Rl> 2 SDs, medicine AREDV
EDV present specialist
opinion

Repeat ultrasound Repeat ultrasound Repeat ultrasound

(Every 2-3 wks) Weekly Twice weekly Weekly Daily
AC & EFW1,2 AC & EFW1, 2 UA Doppler AC & EFW1, 2 UA Doppler
UA Doppler DV Doppler
MCA Doppler after 32 weeks CTG

Delivery Delivery Delivery

Offer delivery by 37 weeks with the Recommend delivery by 37 weeks Recommend delivery if ≥ 34 weeks
involvement of a senior clinician Consider steroids if delivery by CS (even other reports are normal)
Recommend delivery by 37 weeks Consider delivery>34 weeks if Consider Delivery before 34 weeks
if MCA Doppler Pl < 5th centile static growth over 3 weeks if CTG is pathological/Reversed
Consider delivery>34 weeks if flow in Ductus Venosus /umbilical
Recommend steroids if delivery is vein pulsation
static growth over 3 weeks by CS (as per RCOG guidance)
Recommend steroids if delivery is Recommend steroids if delivery
by CS (as per RCOG guidance) <34 weeks

1
Weekly measurement of fetal size is valuable in predicting birth weight and determining size-for-gestational age
2
If two AC/EFW measurements are used to estimate growth; they should be at least 3 weeks apart
3
Use cCTG when DV Doppler is unavailable or results are inconsistent-recommend delivery if STV<3ms
Abbreviations: AC, abdominal circumference; EFW, estimated fetal weight; Pl, pulsatility index; Rl, resistance index; UA, umbilical artery; MCA,
middle cerebral artery; DV ducts venosus;SD, standard deviation; AREDV, Absent/reversed end-diastolic velocities; CTG, cardiotography; STV,
short term variation; SFH, symphysis-fundal height FGR, fetal growth restriction; EDV, end-diastolic velocities.

References :
1. The investigation and management of the small-for-Gestational age fetus. Green Top Guideline No. 31. 2nd Edition. February -2013. Minor
Revision – January 2014.
2. Evidence-based national guidelines for the management of suspected fetal growth restriction: comparison, consensus, and controversy.
Am J Obstet Gynecol. 2018 Feb;218(2S):S855-S868. doi: 10.1016/j.ajog.2017.12.004
3. Fetal Growth Restriction. Practical Guide to High-Risk Pregnancy& Delivery. 3rd Edition. P 105

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28: Pain & Bleeding in Early Pregnancy

A pregnancy of unknown location (PUL) is when1:

 Pregnancy test is positive but
 Pregnancy cannot be seen clearly on ultrasound scan

Reasons:
 Pregnancy is too small or too early to be seen. Pregnancy may not be seen on ultrasound until approximately 3 weeks after conception (at
least 5 weeks from last period).
 Early miscarriage: Pregnancy tests can stay positive for a week or two after a miscarriage.
 Ectopic pregnancy that is too small to be seen. As many as one in five women with a PUL may have an ectopic pregnancy.

Guidelines on management of pregnancy of unknown location (PUL)2

Positive Urinary pregnancy test

Transvaginal ultrasound scan

PUL/Inconclusive scan

Hemodynamically stable Hemodynamically

Hemodynamically unstable Pain
Pain free stable Pain

Expectant Management Admit and Serum hCG

Serum βhCG levels at 0

Consider laparoscopy Consider laparotomy
and 48 hours

<66% increase or <15%

>66% increase in serum
decrease in serum hCG 0-48 >15% decrease in serum hCG 0-48 hours
βhCG 0-48 hours
hours

Intra-uterine pregnancy Ectopic pregnancy Failing PUL

Serum hCG in 48 hrs.

Rescan in1 week to confirm Repeat serum hCG in 1
Rescan if hCG > 1000
Pregnancy location week to confirm failing pregnancy
IU/L

Early intra-uterine Ectopic pregnancy Consider weekly hCG

PUL
pregnancy visualized visualized Monitoring until<25 IU/L

Rescan in 2 weeks to Management as Repeat hCG now and 48

confirm viability clinically indicated hours later

If no pregnancy seen on repeat scan and suboptimal

rise in hCG consider methotrexate (refer to guidelines
on medical management of ectopic pregnancy)
Special points:
hCG pattern:
• Doubling every 48 hours suggestive of normal intrauterine pregnancy
• hCG>1500IU/L: Intrauterine sac likely to be visible in TVS
• Sustained fall is suggestive of miscarriage
• Plateau or slow rise or slow fall or Fluctuating levels suggestive of ectopic pregnancy
References:
1. Bleeding and/or pain in early pregnancy patient information-RCOG
https:// www.rcog.org.uk/en/patients/patient../bleeding-and-pain-in-early-pregnancy/Sep 21, 2016
2. Management of pregnancy of unknown location (PUL).https://www.nuh.nhs.uk/handlers/downloads.ashx?id=6118Emergency Gynecology
SSU_S.Deb Guidelines on Management of PUL

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29: Protocol for Vaginal Bleeding in Early Pregnancy
(Miscarriage/Abortion)

Definition: Vaginal bleeding during first 22wks of pregnancy (WHO)

Symptoms Sign

Signs and Symptoms • H/O Amenorrhea Pallor/ Anemic Uterus may or may
• Early symptoms of pregnancy Raised pulse, low BP not correspond to
Dehydration may be period of gestation,
• Per vaginal bleeding present Os – open/ closed,
• Pain in lower abdomen: (dull/severe/spasmodic) P/V bleeding
• Passage of fleshy mass/clots

Categorize

General Management Recognition

• Rapid evaluation of vital signs

Communication
• Counseling: Pre procedure/during procedure/post procedure and Assurance

Initial Management
• Signs of Shock-may be present
• Resuscitation (if shock is present)
• Analgesic: Inj. Pethidine (if pain)
• IV access & IV fluid (Normal saline/Ringer Lactate solution)
• Blood transfusion if bleeding is excessive

Monitoring & Investigations

Hb%, Blood grouping & Rh typing, USG of lower abdomen

If expertise/facility not available

• Provide first aid
• Counsel patient and family
• Refer

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 Flow chart for Specific Management of Early Pregnancy bleeding (Abortion)
According to Cause of Bleeding

112
Abortion Ectopic Molar
pregnancy pregnancy

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

 Slight P/V bleeding Heavy P/V bleeding H/O expulsion of POC Heavy bleeding / irregular bleeding Mild/Irregular P/V See Protocol
 Dull pain Cramping lower abdominal pain Slight vaginal bleeding Os open/ Closed bleeding/Brownish
 Os closed Uterus corresponds to Os closed Cramping lower abdominal pain discharge
Uterus smaller than H/O partial expulsion of POC Uterus See Protocol
 Uterus corresponds gestational age, Os – open
to gestational age No expulsion of POC gestational age corresponds/smaller than
Mild lower abdominal pain gestational age
No pain, no foetal
movement>20 wks Vaginal Bleeding in
Avoid strenous activity &
sexual intercourse Uterus<12 wks Uterus>12 wks Evacuation of uterus is not early Pregnancy
necessary Uterus<12 wks Uterus>12 wks

EMERGENCY OBSTETRIC AND NEONATAL CARE

USG-Rule out foetal viability
BT/CT/Platelet count to rule
Assess foetal Resuscitation Await Tab.Misoprostol To facilitate
If no complication out DIC
viability by USG, MVA spontaneous expulsion 600 ugm expulsion
Rule out ectopic Antibiotic of POC, To facilitate – follow up after 7 days orally(X1) Tab.
pregnancy, expulsion Oxytocin or 400 ugm Misoprostol
If bleeding stops, infusion sublingually 600 ugm orally Ut eru s>12 w ks
Ensure followup early Uter us<12 w ks
Antenatal care 20 IU in 1L NS/RL single dose or 400 ugm
- If heavy bleeding, OR MVA sublingually
@20 drops/min,
- Pain,fever Antibiotic single dose OR
Then evacuation Tab. To help expulsion
- Assess clinically and Follow up Oxytocin
Reassess if of uterus

STANDARD CLINICAL MANAGEMENT PROTOCOLS AND FLOWCHARTS ON

- USG of uterus Misoprostol 800 Misoprostol 2 tab
bleeding recurs after expulsion if infusion 20 IU
- Antibiotics in 1L NS/RL ugm (4 tab) vaginal - (400 μgm) in post
needed, Antibiotic in posterior fornix vaginal fornix OR
@20 drops/min
Follow up OR 600 ugm (3 Oxytocin infusion 20
Then MVA
after expulsion tab) sub-lingually IU in 1L NS/RL @20
if needed repeated 3 hourly drops/min then
Antibiotic for 3 doses evacuation of uterus
OR MVA after expulsion if
needed,
Antibiotics Close monitoring is
necessary e.g. in
In case of abortion of pregnancy up to 12 weeks pregnancy fertility returns after about 14 days of abortion. So, if scarred uterus
the woman wants to delay the next pregnancy counsel and encourage to use contraceptive immediately Follow up
Antibiotics
May consider tubal ligation if patient desires Follow up

If the women Rh negative husband is Rh positive give inj. AntiD 300 ugm IM to mother
POC- product of conceptus

References:
1. Ipas, VSI, Misoprostol use in post abortion care : A service delivery Tool kit chapel, Hill, Ipas, 2011: 47-48
2. WHO - Safe abortion: Technical and policy guidance for health systems - 2nd edition, Geneva: WHO
3. OGSB - Blue TOP guideline - Standard clinical management prototcols and guidelines September 2012
4. Misoprostol Only Recommended Regimens 2017. FOGO www.figo. org
30: Protocol for Vaginal Bleeding in Early Pregnancy
(Mole/Ectopic)13

Definition: Bleeding pervagina up to 22 weeks of pregnancy due to any cause is known as early pregnancy vaginal
bleeding.

The causes of bleeding are broadly divided into

 Related to the pregnancy: 95% is caused by abortion. Other causes are: Ectopic pregnancy, hydatidiform mole and
implantation site bleeding.
 Associated with pregnancy: Cervical lesions such as vascular ectopy (erosion), cervical polyp, cervical cancer, and
ruptured varicose vein.

Diagnosis: Suspect Tubal abortion /ruptured ectopic Suspect Mole

Clinical and pregnancy
radiological • Exaggerated early pregnancy sign/symptom
• Short period of amenorrhea
evidence • Mild to severe vaginal bleeding during the
• Sudden severe abdominal pain with fainting first 22 weeks of pregnancy
attack
• Pain in lower abdomen: (dull/severe/
• Shoulder tip pain. spasmodic)
• Shock • Altered color P/V discharge/bleeding
• Rigid, tender abdomen, flanks full • Passage of grape like structure
• Fornixes tender/ Tender adnexal mass • Anaemia, dehydration, toxicity or shock
• Uterus bulky • Ultrasonographic evidence of snow-storm
appearance of intrauterine mass.
• Small amount of P/V bleeding.
• Pouch of Douglas- full
• Ultra-sonographic findings: uterus empty,
collection in POD, adnexal mass

General • Rapid evaluation of vital signs-pulse, B.P, anaemia, dehydration, temperature, edema, jaundice.
Management • Resuscitation, if shock.
• IV access & IV fluid: Normal saline/Ringer’s Lactate solution if sign of dehydration or delay in getting
blood.
• Blood transfusion if severe bleeding/ anemic.
• Analgesic: Inj. Pethidine ( if necessary)
• Antibiotic
• Investigations: Blood for Grouping & Rh typing, USG of lower abdomen, Blood for CBC, bhCG,FT4,
TSH, SGPT, Creatinine, HBsAg.
• In case of mole: X-ray chest
• Counseling about:Pre- procedure, per operative and post procedure preparation and assurance.

If expertise/facility unavailable:
• Provide first aid
• Counsel patient and family
• Refer

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 Flow chart for Specific Management of Ectopic Pregnancy/Mole
According to Cause of Bleeding

Ectopic Pregnancy Molar Pregnancy

- Amenorrhea of short
- Amenorrhoea of short duration
duration
- Severe abdominal pain, - Mild to severe P/V bleeding
slight P/Vbleeding - Intermittent cramping lower abdominal pain
- Fainting attack - Severe nausea/vomiting
- Features of shock - Early onset PE
- Cervical motion - Uterus larger & doughy
tenderness positive - Passage of grape like structures
- Tender adnexal mass
- USG confirmation (snow storm appearance)
- Uterus bulky
- hCG-raised than normal

Ruptured Unruptured/Chronic  Suction evacuation under anesthesia, Start

Oxytocin infusion 20 IU in 1Lit. NS @60
drops/min in halfway of evacuation when
uterus becomes smaller.
H/O sharp Symptoms of early pregnancy  Blood transfusion.
pain/fainting/ abdominal/pelvic pain, small  Steps of suction evaluation (Page-102)
shock/pallor, amount of irregular per vaginal
abdominal distension bleeding for long time.  Send mole and placental tissue for
USG-uterus empty histopathology in two containers.
hCG/urine pregnancy test(+ve)

IV fluid, Resuscitation, Laparotomy or Laparoscopy (1) Ensure follow up

Blood for grouping, Rh -salpingectomy/salpingostomy
typing, Barrier method used until hCG is normal, then
Cross matching & Medical Management (in OCP can be used.
blood transfusion. specialized centre)
Immediate laparotomy
Inspect both ovaries &
tubes (1)

Extensive damage to Mild tubal damage Follow up

tube

Unilateral Repair of tube/ Salpingostomy

Salpingectomy

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 Flow chart

Follow up after evacuation

uneventful and complete No Product in uterus
Counseling and advices (all
information recorded in the Molar
48 hours post evacuation Card)
 Serum β-hCG 48 hours post
evacuation
Product in uterus
Before discharge
 Assessment of clinical conditions Check D&C under G/A ,
- Pulse Discharge after counseling and
advices (all information recorded in
- Blood pressure
the Molar Card ) Steps of check D&C
- Anemia
in Page-104
- Heart, lung auscultation
- P/A exam: size of uterus
- P/V bleeding Subsequent weekly follow up of above two
 Counseling groups

 History of amenorrhoea/ irregular per vaginal bleeding,

1 week post evacuation
cough, dyspnoea, headache.
 TVS of the uterus and adnexa for any  Clinical evaluation of general physical condition and
retained product of conception and pervaginal bleeding.
size of the ovary  P/V examination for size of the uterus and ovary.
 Record all information in the Molar  Clinical evaluation of signs symptoms of metastases.
Card  Counseling
 Investigation:
Weekly ßhCG up to 2 normal value.
Then monthly ßhCG up to 6 months.
X-ray chest – 1 month post – evacuation.
 All informations should be recorded in the Molar Card
 Advices
- Strongly recommended not to conceive until ßhCG
level normal for 6 months.
- Contraceptives for 1 year since diagnosis.
- Barrier or combined oral contraceptive pill advised.
- No IUCD or progesterone only contraceptive pill
because of chance of irregular P/V bleeding.

Diagnosis of Gestational Trophoblastic Neoplasia (GTN)

Definition: The malignant forms of GTD are collectively known as Gestational Trophoblastic Tumours or Neoplasia (GTN)
Diagnosis of GTN is based on clinical and biological rather than histological criteria.
FIGO oncology committee recommendations1:
1. bhCG plateau for 4 consecutive values over 3 weeks (days 0,7,14,21)
2. bhCG level increase of more than 10% for three consecutive valuesover 2-weeks (days 0,7, and 14)
3. bhCG persistence 6 months after molar evacuation.
Histological confirmation of metastases should be avoided since the punction may causes excessive bleeding2. For any
woman presenting in her reproductive age with metastatic disease of unknown origin, bhCG should be checked to exclude
a GTN3.

References:
1. FIGO oncology committee. FIGO staging for gestational trophoblastic neoplasia2000. FIGO oncology committee. Int JGynaecol Obstet. 2002 Jun;77
(3):285-7.
2. Mangili G, Lorusso D, Brown J, PfistererJ, Massuger L, Vaughan M, et al. Trophoblastic diseases review for Diagnosis and Management: A Joint Report
From the International Society for the Study of Trophoblastic disease, European Organization for the Treatment of Trophoblastic Diease, and the
Gynaecologic Cancer Inter Group. Int J Gynecol Cancer.2014 Nov;24(9Suppl3): s109-16.
3. Bolze P-A, Attia J, Massardier J, Seckl MJ, Massuger L, van Trommel N, et al. Formalisedconsensus of the EuropeanOrganisation for Treatment of
Trophoblastic Diseases on management of gestotional trophoblastic diseases. Eur J Cancer. Elsevier Ltd; 2015 Sep. 1;51(13): 1725-31.

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 Protocol for Suction/Evacuation of Mole

a) Immediate hospitalization is mandatory once a case is diagnosed as molar pregnancy.

1. Thorough evaluation of general physical condition which includes anaemia, dehydration, fever, pulse, BP, infection,
electrolyte imbalance, hyperthyroidism and pre-eclampsia.
2. Evaluation of uterine size and condition of cervix.
3. Evaluation of medical co-morbidities which includes diabetes, hypertension, cardiac disease, respiration problem.
4. Investigation to be done are: CBC, X-ray Chest P/A view, urine R/M/E and C/S, FT4, TSH, Serum creatinine, SGPT,
HBsAg and Blood sugar 2 hrs after 75 gm of glucose and USG if not done before.
c) Pre-operative preparation
1. Correction of anaemia by blood transfusion.
2. Injectable antibiotic.
3. Correction of electrolyte imbalance and dehydration (if any) by Hartmann’s solution.
4. Treatment of Hyperthyroidism, PE, Diabetes (if any)
5. Proper counseling.
6. Intravaginal misoprostol 200mg if cervix is long, tubular and firm.
7. Keep 2 bags of whole blood ready for transfusion if required.
8. Keep laparotomy set ready if the uterine size is >12 weeks (may be required if bleeding is uncontrolled or
perforation of uterus occurs or intraperitoneal haemorrhage occurs). In these situations, hysterectomy, hysterotomy
or bilateral internal iliac artery ligation may be required.
d) Procedure
Electronic suction/evacuation is the method of choice for evacuation of mole regardless of size of the uterus. Manual MR
syringe and Karman cannula <10mm size is not suitable for S/E of molar tissue

STEPS OF PROCEDURE:
1. Anesthesia preferably by G/A.
2. Bimanual P/V examination

Cervix closed Cervix dilated

Gradual dilatation by Procedure

Hegar’s dilator started

3. Selection of appropriate size cannula and sucker tube.

4. Sucker machine is checked.
5. Depth of uterine cavity assessed by uterine sound.
6. Sucker tube connected to cannula.
7. A wide bore cannula >10mm is introduced more than halfway to the uterine cavity, not touching the fundus.
8. Sucker machine is started.
9. The cannula is rotated in the upper segment of uterine cavity by very short in and out stroking motion.
10. Best accomplished by slowly rotating 180o in one direction, then reversing direction.
11. Halfway through the procedure, an oxytocin drip is started.
12. Operator should be aware of the capacity of the bottle of sucker machine, as vacuum capacity of the machine falls markedly
when it is half-filled with aspirate.
13. Operator should also be aware of the size of the vesicle removed and should be marked in the operation note.
14. Some molar tissue collected for HPE.
15. During the whole procedure, one hand of the assistant or operator should be kept on the fundus of the uterus to guard against
perforation, reduction in size of uterus and to provide continuous gentle massage which helps in contraction of the uterus.
16. At the end of the procedure, per-rectal misoprostol is given to control any unwanted P/V bleeding and Inj. Ergometrine if
excessive bleeding.

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Protocol for check D&C for Incomplete Evacuation of Molar Pregnancy

1. Thorough evaluation by history, clinical examination and investigation

¡ History of evacuation of mole followed by irregular P/V bleeding for >2 weeks
¡ Clinical examination for-
- Anaemia – corrected by blood transfusion
- Dehydration – corrected by fluid
- size and consistency of uterus and cervix

¡ Uterus firm, indicate contracted and less molar tissue in the uterus
¡ Uterus soft and doughy, indicate large amount of molar tissue in the uterus
¡ Cervix firm, tubular which needs use of misoprostol for ripening- 1 hour before procedure.
¡ Cervix-soft, os open which indicate ripe cervix.
¡ Investigations
- CBC, Serum β-hCG, CXR, P/A view, Urine R/M/E & C/S, S.creatinine, SGPT, HBs Ag, TSH, FT4-if not done
earlier

2. Procedure: Usually electronic suction machine is not required for check D&C.
b. Use of oxytocin 20IU in 1000ml Hartman solution at the onset of procedure.
c. Dilatation of cervix required by maximum size dilator.
d. First removal of molar tissue by maximum size sponge holding forcep.
e. Removal of molar tissue by using maximum size curette.
f. Introduce curette up to fundus each time.
g. Curettage of anterior wall - 3-4 times.
h. Curettage of posterior wall - 3-4 times.
i. Curettage of 2 lateral wall - 3-4 times.
j. Curettage of fundus -3-4 times, up to completeness.
k. Sponge holding forcep required in case of large amount of tissue.
l. All products are sent for HPE.
m. Give gentle massage.
n. Give- Inj. Ergometrine and per-rectal misoprostol to control heavy bleeding.
o. Advice given for serum β-hCG 48 hour after check D&C.
p. Patient is advised to come with the report of serum β-hCG and histopathology report.

If histology report normal, she is asked

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31: Protocol for Septic Abortion

Definition: Abortion complicated with infection is called septic abortion

Symptoms • Amenorrhea Features of Peritonitis/ Pervaginal

and Signs • H/O induced abortion/MR Internal Hemorrhage/ • Enlarge uterus
• Vaginal bleeding, foul smelling discharge Intestinal injury
• Foul smelling
• Abdominal pain • Vomiting
discharge
• Fever, chills • Temp: High or sub
• Cervical motion
normal
• Passage of product of conception tenderness +ve
• Dehydration
• Features of shock • POD-Full
- Hypothermia • Raised pulse, low BP
• Pelvic mass
- Rapid pulse, low BP • Abdominal distension
- Oliguria • Rebound tenderness
- Respiratory distress • Rigid abdomen
- Reduced level of consciousness • Absent bowel sound
• May be anaemia, anuria, Jaundice,
hemoglobinuria, hemosidernuria due to
intravascular hemolysis

Categorize 1. Only S/S of infection

2. Retained product of conception
3. Severe abdominal pain- uterine perforation
4. Paralytic Ileus/suspected bowel injury

General 1. Hospital admission

Management 2. Recognition: Assessment of maternal condition
3. Communication about the etiology& consequences
Reassurance/confidentiality
4. Initial management
• IV access: IV fluids Normal saline/Ringer’s lactate
• Maintenance of nutrition
• Antibiotics: Immediate injectable broad spectrum antibiotics
Ampicillin+ Gentamycin and metronidazole or clindamycin + Gentamycin (Ref: Marck Manual)
• Pain Relief: Inj. Pethidine
• Antipyretic and cold sponging- if high temperature
• Catheterization
• Strict fluid balance, maintain intake output chart
• Inj. Tetanus toxide 0.5 ml IM & Tetanus Immunoglobulin IM
5. Monitoring and investigation
• Monitor temperature, Pulse, BP, respiration, Intake output
• Inv: CBC, Blood Grouping & Rh typing, S.creatinine, electrolytes, HVS/urine/blood for C/S, USG
of abdomen, X-ray abdomen in erect posture including both doses diaphragm as necessary
• Blood for cross matching.

If expertise/facility unavailable:
• Provide first aid
• Counsel patient and family
• Refer

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 Flow Chart for Specific Management of Septic Abortion
SCREEN FOR LIFE THREATENING COMPLICATION AND PREPROCEDURE COUNSELING

Shock Vaginal bleeding Infection Uterine injury+

intestinal injury,
Treat Paralytic Ileus
shock
See Assess severity
protocol of infection

Retained Cervical/ Perforation Immediate injectable antibiotics H/O induced abortion/

product of Vaginal tear of uterus MR,
conception Fever, shock, absent
bowel sound
Abdominal pain/
distension, vomiting,
tense & hard abdomen,
MVA/ Repair of Laparotomy Metritis/Infection Pelvic Peritonitis
rebound tenderness,
Dilatation Cervical/ Repair/ Confined to abscess
During procedure:
&Curettage vaginal tear, subtotal uterus
excessive bleeding/
laceration hysterectomy
instrument penetrates
Refer (if Shock, beyond expected
facilities not vomiting, Pain, size of uterus/loss
available) abdominal
Retained POC Pelvic pain/ of resistance/fat or
distension distension, omentum coming
Swinging rigidity through os
Fever, pain,
temperature rebound Plain X-ray abd: sub
foul, smelling,
Diarrhea tenderness diaphragmatic gas
discharge tender
Tender uterus absent bowel
uterus, shock
POD- Full sound

Treat shock Colpotomy NPO, NG

Antibiotics with drainage suction
Prompt of PUS/ IV nutrition Manage shock,
evacuation Laparotomy Antibiotics Supportive care
MVA/Dilatation (NPO, NG suction,IV
&Curettage fluid)
Inj. Antibiotics
If fever Not Observation
All patients should be persists>72 hrs responding
counselled properly while re-evaluate within 48-72
providing PAC hrs

Generalized/ Laparotomy
spreading
Peritonitis not Peritoneal Prepare for
responding to lavage/ Explore Laparotomy
conservative gut injury Consultant surgeon
treatment Hysterectomy- Check gut-May need
Necrotic uterus ileostomy/colostomy /
Refer

Laparotomy

Peritoneal
Lavage/
Hysterectomy

Foot note
Antibiotics: Ampicillin IV 2 gm every 6 hours+Gentamycin 80 mg IV every 8 hours+Metronidazole 500 mg IV every 8 hours
POD: Pouch of Douglus
POC- Product of conception, PAC= Post Abortion Care

Reference:
1. Technical standard & service delivery guideline: Post Abortion Care DGFP, MOHFW and Engender health

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Regime-Protocol

Antibiotic Regime for Different Condition

1. Delivery and Routine antibiotic prophylaxis is not recommended for women with uncomplicated vaginal
Episiotomy birth.
One course of antibiotic may be given when membrane ruptures for > 6 hours during
vaginal delivery
Dose: Cap. Amoxicillin 500 mg 8 hourly/ Cap Cephalosporine 500 mg 6 hourly for 5 days
Routine antibiotic prophylaxis is not recommended for women with episiotomy. Second
degree perineal tear is anatomically similar to episiotomy and does not warrant use of
prophylactic antibiotics
Where episiotomy wound extends to become third or fourth degree perineal tear
prophylactic antibiotics should be administered

2. Caesarean Section One course of injectable antibiotic should be given after cord is clamped following delivery
of the baby or 30 minutes before the start of the procedure
Regime:
Inj. Amoxicillin 1 gm IV and repeat 8 hourly for 3 doses +Inj. Metronidazole 500 mg IV
slowly for 3 doses
OR Inj. Cephalosporine 1 gm IV and repeat 6 hourly for 4 doses + Inj. Metronidazole 500
mg IV slowly for 3 doses
OR Inj. Cephalosporine 1 gm IV single dose, Inj. Metronidazole 500 mg IV slowly for 3
doses
Followed by Cap. Amoxicillin 500 mg 8 hourly or Cap. Cephalosporine 500 mg 6 hourly for
5 days

3. Eclampsia Inj. Amoxicillin 1 gm IV and repeat 8 hourly for 5 days/Inj. Cephalosporine 1 gm IV and
repeat 6 hourly for 5 days

4. Manual removal of
placenta

5. Inversion of uterus Regime: Broad spectrum combination antibiotics IV route Inj Amoxicillin 2 gm stat and 1
gm 8 hourly + Inj. Gentamycin 5 mg/kg-24 hourly + Inj. Metronidazole 500 mg 8 hourly
6. Prolognedlabour continue same dose same route until the patient is symptom free for 72 hours

7. Obstructed labour

8. Puerperal sepsis

9. Septic Abortion

10. Chorioamnionitis

11. Minor procedures Regime: Single dose orally Ciprofloxacin 500 mg or Doxicycline 100 mg

Reference:
1.Clinical Practice Guideline SOGC , No 247 , 2017
2. WHO recommendations Intrapartum care for a positive childbirth experience 2018

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32: Flow chart for Post Abortion Care (PAC)

Comprehensive post abortion care includes both curative and preventive care. I+
consists of three key elements-
- Emergency management for complications of spontaneous or induced
abortion- bleeding, infection and injury
- Post abortion contraception counseling and services
- Coordination between emergency post abortion treatment and
comprehensive reproductive health care services (RHCS)

PAC

Emergency management of Post Abortion

complication of abortion Contraception

Bleeding Infection Incomplete Injury Hormonal (pills, - Immediately RHCS

Abortion Cervical/ injections, - RTI
Threatened Protocol Protocol vaginal-repair implants)
abortion of Septic management Perforation of - Cervical
Complete Abortion for abortion uterus Condom - Immediately Cancer &
abortion - Laparotomy: breast cancer
Intrauterine - Immediately screening
Incomplete repair/
device (IUD) - If infection is present or
abortion hysterectomy - Management
suspected, delay insertion
Missed Injury to gut- of subfertility
until it is cleared of.
abortion laparotomy &
- If Hb is less than 7 g/dl, - STDs
repair
delay until anaemia is - Other
See
corrected gynaecological
Protocol
- Provide an interim method or medical
(e.g. condom) problem

Voluntary tubal - Immediately

ligation - If infection is present or
suspected, delay surgery
until it is cleared of
- If Hb is less than 7 g/dl,
delay until anaemia is
corrected
- Provide an interim method
(e.g. condom)

Post abortion counseling

Pre procedure Counseling: The patient’s overall physical condition, result of physical and pelvic examinations and
laboratory tests, the time frame for treatment and follow up, treatment procedure and its risks and benefits post abortion
care, warning signs, available contraceptive methods, preventive measures for the sexually transmitted infections,
information regarding other reproductive health services. During procedure counseling: Positive empathetic, verbal/non-
verbal communication.
Post Procedure counseling: Possible side effects and warming signs. How to take care of herself at home, the importance
of follow up visit, available contraceptive methods, The benefits and limitations of all contraceptive methods and help
choose her the appropriate one
Foot Note:
In case of abortion up to 12 weeks pregnancy fertility retuns after 14 days of abortion. Counsel and encourage using contraceptive
If the women is Rh negative& husband is Rh positive give inj. AnitD-250 ugm IM to mother

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33: Protocol for Antibiotic Therapy

1. Antibiotic therapy
• Infection during pregnancy and the postpartum period may be caused by a combination of organisms including aerobic and anaerobic
cocci and bacilli.
• Uterine infection can follow an abortion or childbirth and is one of the cause of maternal death.
• Broad spectrum antibiotics are often required to treat these infections.
• Antibiotics should be started based on the woman’s clinical condition.
• If there is no clinical response, culture of vaginal discharge, pus or urine may help in choosing alternate antibiotics. In addition, blood
culture may be done if septicemia is suspected.
• In cases of unsafe abortion and non-institutional delivery, anti-tetanus prophylaxis should also be provided – if necessary
• In case of puerperal sepsis and unsafe abortion culture sensitivity of collected materials to be sent before starting antibiotics

2. PROVIDING PROPHYLACTIC ANTIBIOTICS

1. Performing certain obstetrical procedures (e.g. caesarean section, manual removal of placenta) increases morbidity due to infection.
2. This risk can be reduced by:
• following recommended infection prevention practices ;
• Providing prophylactic antibiotics at the time /before the procedure.
3. Prophylactic antibiotics are given to help prevent infection.
4. If a woman is suspected to have or is diagnosed as having an infection, therapeutic antibiotics are more appropriate.
5. Give prophylactic antibiotics 30 minutes before the start of a procedure, when possible, to allow adequate blood levels of the antibiotic at
the time of the procedure.
6. In caesarean section, prophylactic antibiotics is usually given when the cord is clamped after delivery of the baby
7. One dose of prophylactic antibiotics is sufficient.
8. The choice of antibiotic for C/S is single dose of 1st generation cephalosporin. In case of Allergic to Penicillin, Clindamycin/ Erythromycin
can be used.
9. If the procedure lasts longer than 6 hours or blood loss is 1500 mL or more, give a second dose of prophylactic antibiotics to maintain
adequate blood levels during the procedure.
10. In patient with morbid obesity (BMI > 35 Ibs), doubling the antibiotic dose may be given.

3.Therapeutic Antibiotics- when the women is suspected to have or is diagnosed as having infection
• As a first defense against serious infections, give a combination of antibiotics:
o Inj Amoxicillin/Cephalosporin 2g IV every 6 hours or Inj. ceftriaxone
o PLUS Gentamicin 5 mg/kg body weight IV every 8 hours
o PLUS Metronidazole 500 mg IV every 8 hours
Note: If the infection is not severe, Amoxicillin 500 mg by mouth every 8 hours can be used instead of ampicillin. Metronidazole can be given by
mouth instead of IV
• If the clinical response is poor after 48 hours, ensure adequate dosages of antibiotics are being given, thoroughly re-evaluate the woman
or other sources of infection or consider altering treatment according to reported microbial sensitivity (or adding an additional agent to
cover anaerobes, if not yet given).
• If culture facilities are not available, re-examine for pus collection especially in the pelvis, and for non- infective causes such as deep vein
and pelvic vein thrombosis. Consider the possibility of infection due to organisms resistant to the above combination of antibiotics:
o If staphylococcal infection is suspected, add:
• Flucloxacillin 1 g IV every 4 hours;
• OR Vancomycin 1 g IV every 12 hours infused over 1 hours
o If Clostridial infection or Group A hemolytic streptococci is suspected, add penicillin 2 million units IV every 4 hours;
o If neither of the above are possibilities, add ceftriaxone 2 g IV every 24 hours
Note: To avoid phlebitis, the infusion site should be changed every 3 days or at the first signs of inflammation
• If the infection does not clear, evaluate for the source of infection
• For the treatment of metritis, combinations of antibiotics are usually continued until the woman is fever free for 48 hours
• Discontinue antibiotics once the woman has been fever free for 48 hours
• There is no need to continue with oral antibiotics, as this has not been proven to have additional benefit.
• Women with blood stream infections, however, will require antibiotics for at least 7 days.

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34: Infection Prevention Practices

Introduction
Infections are caused by microorganisms which are tiny organisms that can only be seen under microscope.
Microorganism are everywhere i.e on skin, in air, in people, animals, plants, soil and water.

Who are at risk of infection?

Health care provider, Clients, Community.

Antiseptics: is a chemical agent used to reduce the number of microorganisms on skin and mucous membrane without
causing damage or irritation.
Antiseptics are used for:
 Skin, cervical, or vaginal preparation before a clinical procedure
 Surgical scrub
 Handwashing before invasive procedure, or contact with client at high risk of infection
Common antiseptics are – Betadine, Savlon, Chlorhexidine ( Hibitane, Hibiscrub)

Disinfectants: is a chemical agent used to kill microorganism on inanimate objects such as instruments and surfaces.
Disinfectants are used in three different ways:
 During decontamination
 During chemical HLD & sterilization
 During house keeping
Common disinfectants are – Phenol, Lysol, Chlorine, Gluteraldehyde ( Cidex)

Decontamination Process that makes inanimate objects safer to be handled by staff before cleaning (i.e., inactivates
HBV, HCV and HIV and reduces, but does not eliminate, the number of other contaminating microorganisms).

Cleaning Process that physically removes all visible dust, soil, blood or other body fluids from inanimate objects. It
consists of thoroughly washing with soap or detergent and water, rinsing with clean water and drying8.

Principles of Infection Prevention

 Consider every person (client or staff) infectious
 Wash hands – It is most practical procedure for preventing cross-contamination (person to person).
 Wear gloves- before touching anything wet, broken skin, mucous membranes, blood or other body fluids
(secretions or excretions) or soiled instruments and other items.
 Use physical barriers- (protective goggles, face masks and aprons) if splashes and spills of any body fluids
(secretions or excretions) are anticipated.
 Use safe work practices:
- Not recapping or bending needles
- Safely passing sharp instruments
- Properly disposing of medical waste

Hand Hygiene Practices

Antimicrobial soaps or detergents are not more effective than plain soap & clean water in reducing the risk of infection
when used for routine hand wash providing the water quality satisfaction.
Hand hygiene significantly reduces the number of disease-causing microorganisms on hands and arms and can minimize
cross-contamination (e.g., from health worker to patient)

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Hand Washing
The purpose of handwashing is to mechanically remove soil and debris from the skin and reduce the number of transient
microorganisms. Handwashing with plain soap and clean water is as effective as washing with antimicrobial soaps. In
addition, plain soap causes much less skin irritation.

Hand washing should be done before:

• examining (direct contact with) a patient; and
• putting on sterile or high-level disinfected surgical gloves prior to an operation, or examination gloves for routine
procedures such as a pelvic examination.

Hand washing should be done after:

• any situation in which hands may become contaminated, such as:
¡ handling soiled instruments and other items;
¡ touching mucous membranes, blood or other body fluids (secretions or excretions);
¡ having prolonged and intense contact with a patient; and removing gloves.

Gloves
Some Do’s and Don’ts about Gloves
• Do wear the correct size glove, particularly surgical gloves. A poorly fitting glove can limit your ability to perform the
task and may be damaged (torn or cut) more easily.
• Do change surgical gloves periodically during long cases as the protective effect of latex rubber gloves decreases
with time and in apparent tears may occur.
• Do keep fingernails trimmed moderately short (less than 3 mm or 1/8 inch beyond the finger tip) to reduce the risk
of tears.
• Do pull gloves up over cuffs of gown (if worn) to protect the wrists.
• Do use water-soluble (nonfat-containing) hand lotions and moisturizers often to prevent hands from drying,
cracking and chapping due to frequent handwashing and gloving.
• Don’t use oil-based hand lotions or creams, because they will damage latex rubber surgical and examination
gloves.
• Don’t use hand lotions and moisturizers that are very fragrant (perfumed) as they irritate the skin under gloves.
• Don’t store gloves in areas where there are extremes in temperature (e.g., in the sun, or near a heater, air
conditioner, ultraviolet light, fluorescent light or X-ray machines). These conditions may damage the gloves (cause
breakdown of the material they are made of), thus reducing their effectiveness as a barrier.

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 Infection Prevention Practices
Hand Washing

Steps of Routine Hand Washing (10-15 sec) Steps of Surgical hands scrub (3-5 minutes)
Step-1 Step-1
Remove all jewelry Remove all jewelry from
Wearing and
from the hands andRemoval Gloves the hands and wrists. Wear
wrists. Wet hands with OT dress masks, cap and
running water foot wear. Wet hands and
forearms thoroughly

Step-2 Step-2
Rub hands together Clean under each fingernail
with soap and lather with a stick or brush. It is
well, covering all important for all surgical
surfaces staff to keep fingernails
short

Step-3 Step-3
Vigorously weave nails, Holding hands up above
fingers and thumbs the level of the elbow, apply
together and slide them the antiseptic. Using a
back and forth for 10- circular motion, begin at the
15 second fingertips of one hand and
later and wash between
the fingers, continuing from
Step-4
fingertip to elbow. Repeat
Rinse hands under
this for the second hand
a stream of clean,
and arm. Continue washing
running water until all
in this way for 3-5 minutes.
soap is gone
Step-4
Rinse each arm separately,
Step-5 fingertips first, holding
Blot hands dry with a hands above the level of
clean towel or allow the elbow
hands to air-dry

Step-5
Using a sterile towel, dry
the arms from fingertips to
elbow using a different side
of the towel on each arm.

Step-6
Keep the hands above the
level of the waist and do
not touch anything before
putting on sterile surgical
gloves.

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Steps of putting on sterile gloves Steps of Removing Surgical Gloves

Step-1 Step-1
Prepare a large, clean, Rinse gloved hands in a
dry area for opening the bucket of decontamination
package of gloves and solution to remove blood
perform a surgical hand or other body fluids.
scrub and ask someone
else to open the package of
gloves Step-2
Grasp one of the gloves
Step-2 near the cuff and pull it
Open the inner glove partway off. The glove
wrapper, exposing the will turn inside out. It is
cuffed gloves with the palms important to keep the
up. The first gloves should first glove partially on the
be picked up by the cuff only hand before removing the
second glove to protect
Step-3 from touching the outside
Pick up the first glove by surface of either glove with
the cuff, touching only the the bare hands
inside portion of the cuff
(the inside is the side that Step-3
will be touching the skin of Leaving the first glove
the service provider). While over the fingers, grasp the
holding the cuff in one hand, second glove near the cuff
slip the other hand into the and pull it part of the way
glove (pointing the fingers off. And pull it part of the
of the glove toward the floor way off. The glove will turn
will keep the fingers open). inside out. It is important
Be careful not touch any to keep the second glove
thing and hold the gloves partially on the hand to
above the waist level. protect from touching the
outside surface of the first
Step-4 glove with the bare hand.
Pick up the second glove
by sliding the fingers of Step-4
the gloved hand under the Pull off the two gloves
cuff of the second glove. at the same time, being
Be careful not contaminate careful to touch only the
the gloved hand with the inside surfaces of the
ungloved hand as the gloves with bare hands.
second glove is being put
on. Step-5
If the gloves are
Step-5 disposable or are not
Put the second glove on intact, dispose them
the ungloved hand by properly. If they are to be
maintaining a steady pull processed for reuse, place
through the cuff. them in a container of
decontamination solution.

Step-6
Adjust the glove fingers until
the gloves fits comfortably

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Instruments Processing Decontamination
Decontamination
Steps of Decontamination
Step-1 Step-2
Cleaning Immediately after use, After 10 minutes, remove the
decontaminate instruments and items from the chlorine solution
other items by placing them and either rinse with water or
Preferred method Accepted method
in a plastic container of 0.5% clean immediately. Do not leave
chlorine solution. Let them soak items in the solution for more
Sterilization High-level Disinfection for 10 minutes. A container of this than 10 minutes, since excessive
solution should be kept in every soaking in the solution can
operating theater and procedure demandge instrument and other
room so that service provider can items. Use utility gloves when
put used instruments directly into removing instruments and other
the bucket. items from a chlorine solution.
Steam Dry Heat Chemical Boiling Steaming Chemical

Use or
Storage

Cleaning High Level Disinfection (HLD)

Steps of Cleaning Steps of High Level Disinfection (HLD) by boiling
Step-1 Step-1
Using a soft brush or old toothbrush, Decontaminate and clean all items to
detergent and water, scrup instruments be placed in a sterilizer/boiler for HLD
and other items vigorously to completely
remove all blood, other body fluids, tissue,
and other foreign matter. Hold instruments
and other items under the surface of the
water while scrubbing and cleaning to Step-2
avoid splashing. Disassemble instruments Water must touch all surfaces for
and other items with multiple parts, and HLD to be achieved, completely
be sure to brush in the grooves, teeth, submerge all items in the water in the
and joints of items where organic material pot or boiler. Open all hinged items
can collect and stick. and disassemble those with sliding or
multiple parts. Place any bowels and
containers upright, not upside-down,
and fill with water.
Step-2
Rinse items thoroughly with clean water Step-3
to remove all detergent. Any detergent left Cover the pot or close the lid on the
on the items can reduce the effectiveness boiler and bring the water to a gentle,
of further chemical processing rolling boil. When the water comes
to a rolling boil, start timing for 30
minutes. Use a timer or make sure to
record the time that boiling begins.
From this point on, don not add or
Step-3 remove any water and do not add any
Allow items to air dry (or dry them with a items to the pot or boiler. Lower the
clean towel) heat to keep the water at a gentle,
rolling boil.

Step-4
After 30 minutes, remove the items
using dry, HLD pickups (lifters, cheatle
forceps) place the items on an HLD
tray or in an HLD container.

Step-5
Allow to air dry before use or storage.
Use items immediately or keep them
in a covered, sterile or HLD container
for up to one week.

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Chemical HLD Stem Sterilization (Autoclave)
Steps of Chemical HLD Steps of Steam Sterilization
Step-1 Decontaminate, clean, and thoroughly dry all Step-1 Decontaminate, clean and dry all instruments and other items to be sterilized
instrument and other items to be processed.
Water from wet items will dilute the chemical
solution, thereby reducing its effectiveness. Step-2 Open or unlock all jointed instruments and other items and disassemble
those with sliding or multiple parts. This allows steam to reach all surface of
the items. Avoid arranging the instruments and other items together tightly,
Step-2 When using a glutaraldehyde solution: Prepare because this prevents steam from reaching all surfaces.
the solution according to the manufacturer’s
instruction. After preparing the solution, put
it in a clean container with a lid. Mark the Step-3 If instruments and other items are to be wrapped before steam sterilization,
container with the date the solution was use two layers of paper, newsprint, or cotton or muslin fabric (do not use
prepared and the date it expires. canvas). Instruments and other items should not be placed in a closed
When using a chlorine solution: Prepare container. If drums are being used, make sure the holes of the drum are open.
the 0.5% chlorine solution as described for
decontamination. Fresh solution should be
made each day, or more often if the solution Step-4 In general, sterilize wrapped items for 30 minutes and unwrapped items for 20
becomes cloudy. Put the solution in a clean minutes at 121 degrees C (250 degree F) and 106 kPa (15lb /in2) pressures.
container with a lid. (Do not begin timing until the autoclave reaches the desired temperature an d
pressure).

Step-3 Open all hinged items and disassemble those

with sliding or multiple parts. The solution Step-5 Arrange all packs, drums, or unwrapped items in the chamber of the autoclave
must contact all surfaces in order for HLD to in a way that allows steam to circulate freely.
be achieved. Completely submerge all items
in the solution. All parts of the items should be
under the surface of the solution. Place any Step-6 If the autoclave is automatic, the heat will shut off and the pressure will began
bowels and containers upright, not upside- to fall once the sterilization cycle is complete. If the autoclave is not automatic,
down, and fill with the solution. turn off the heat or remove the autoclave from the heat source after 30
minutes if items are wrapped, 20 minutes if items are unwrapped. Wait until
the pressure gauge reads “zero” to open the autoclave. Open the lid or door to
Step-4 Cover the container, and allow the items to allow the remaining steam to escape. Leave instruments packs or items in the
soak for 20 minutes. Do not add or remove autoclave until they dry completely, which can take up to 30 minutes.
any instruments or other items once timing has
begun.
Step-7 Remove the packs, drums, or unwrapped items from the autoclave using
sterile pickups. To prevent condensation after removing packs or drums from
Step-5 Remove the items from the solution using dry, the autoclave, place them on a surface padded with sterile paper or fabric until
HLD pickups (Lifters, cheatle forceps) they are cool. Wait until the packs, drums, or items reach room temperature
(which may take up to several hours) before storing.

Step-6 Rinse thoroughly with boiled water to remove

the residue that chemical sterilants leave on Step-8 Store items properly. Proper storage is as important as the sterilization
items; this residue is toxic to skin and tissue process itself:
Wrapped Items: Under optimal storage condition and with minimal handling,
proper wrapped items can be considered sterile as long as they remain
Step-7 Place the items on an HLD tray on in an HLD intact and dry. For optimal storage, place sterile packs in closed cabinets in
container and allow to air-dry before use or areas that are not heavily trafficked, have moderate temperature, and are
storage. Use items immediately or keep in a dry or of low humidity. When in doubt about the sterility of a pack, consider it
covered, dry, HLD container and use within contaminated and re sterilizes it.
one week. Unwrapped items: Use unwrapped items immediately after removal from the
autoclave or keep them in a covered, sterile container.

References:
1. 1.Infection prevention practices Standard and Guideline Directorate General of Health Services, Ministry of health and Family Welfare 2003
2. If tap water is contaminated, use water that has been boiled for 10 minutes and filtered to remove particulate matter (if necessary), or use
chlorinated water—water treated with a dilute bleach solution (sodium hypochlorite) to make the finalconcentration 0.001%
3. Pereira LJ, GM Lee and KJ Wade. 1997. An evaluation of five protocols for surgical handwashing in relatin to skin condition and microbial
counts, J Hosp Infect 36(I):49-65.
4. Pereira LJ, GM Lee and KJ Wade. 1990. The effects of surgical handwashing routines on the microbial counts of operating room nurses. Am J
Infect Control 18(6):354-364.
5. National Institute for Occupational Safety and Health, Department of Health and Human Services (NIOSH). 1997. NIOSH Alert; Preventing
Allergic Reaction to Nature Ruber Latex in the Workplace. No. 97:135.

128 STANDARD CLINICAL MANAGEMENT PROTOCOLS AND FLOWCHARTS ON

EMERGENCY OBSTETRIC AND NEONATAL CARE
Essential Drug List &Equipment

1. Infusion-Normal saline
2. Infusion- Hartman Saline
3. Inj. Amoxicilin 500mg
4. Inj. Metronidazole 500mg
5. Inj. Gentamycin 80mg
6. Inj. Oxytocin
7. Inj. Ergometrine
8. Tab. Misoprostol
9. Inj. Magnesium Sulphate ampoule (5ml/2.5gm 50% solution)
10. Inj. Magnesium Sulphate- bottle (Nalepsin) (4 gm/100 ml 4% solution)
11. Inj. Diazepam
12. Inj. Labetalol
13. Inj. Hydralazine
14. Inj. Frusemide
15. Inj. Dopamine
16. Inj. Roxadex (Dexamethasone)
17. Inj. Hydrocortisone
18. Inj. Adrenaline
19. Distilled water
20. Tab. Nifidipine
21. Nifidipine gel
22. Saline set
23. Transfusion set
24. IV canula I6G/I8G/21G
25. Foley’s catheter
26. Urobag
27. Sterile Gloves
28. Umbo bag- adult and baby
29. Tongue depressor
30. Airway tube
31. Syringe 5/10 cc
32. Ryles tube
33. Test tube
34. Condom packet
35. Sterile threads
36. BP machine
37. Stethoscope
38. Doppler
39. Plain rubber catheter

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EMERGENCY OBSTETRIC AND NEONATAL CARE 129
Reference:
1. WHO recommendations on antenatal care apps: who.int/iris/bitstream/10665/250796/1/9789241549912
2. WHO recommendations on antenatal care for a positive pregnancy experience, 2016 p- 23,101
3. Emergency Obstetric Care. Quick Reference Guide for Front line Provider Maternal & Neonatal Health JHPIEGO; pdf.usaid.govt/pdf-docs/PNACY 580 pdf
4. Guidelines on 8 key evidence based practices on labour; www.commonhealth.in/pdf/8.pdf
5. WHO recommendations Intrapartum care for a positive childbirth experience 2018 ISBN 978-92-4-155021-5
6. ACOG Practice Bulletin No-107
7. WHO & FIGO recommended regimen 2017
8. A Clinical Guideline for the Induction of Labour (IOL) Process Norfolk and Norwich University Hospital (NHS), August 2016 to review 2019
9. Integrated Management of Pregnancy and Childbirth (IMPAC)
10. Queensland Clinical Guidelines
11. SOGC Clinical Practice Guideline
12. Clinical guidelines of Management of normal labour and prolonged labour in low risk patients, Mid Essex Hospital Services( NHS) , 2015
13. WHO recommendations Intrapartum care for a positive childbirth experience WHO,ISBN 978-92-4-155021-5,2018
14. WHO recommendations on postnatal care of mother and newborn; apps.who.int/iris/bitstream/10665/97603/1/97
Maternal Health Standard Operating Procedures(SOP) Volume-1
15. www.tensteps.org/ten-fects-breastfeeding.shtml(updated August 2017)
16. MOH NURSING CLINICAL PRACTICE GUIDELINE, SINGAPORE 2002.
17. Management of Breastfeeding for Healthy full terms infants revised in 2014
18. Antepartum Haemorrhage, Royal College of Obstetricians &Gynecological, Green-top guideline No-63, Nov-2011.
19. Foetal distress –signs of Foetal distress and treatment https//patient.info>doctor> fetal distress
20. Intrapartumfoetal distress – RCOG; http;//wwwrcog.org,uk
21. Preterm Prelabour Rupture of Membranes (Green-top Guideline No. 44);
https://www.rcog.org.uk/en/guidelines-research-services/guidelines/gtg44 Oct 1, 2010
22. Practice Guidelines. ACOG Guidelines on Premature Rupture of Membranes. Am Fam Physician. 2008 Jan 15;77(2):245-246.
23. Practical guide to High Risk pregnancy 3rd edition By Fernando Arias. Page 240
24. Birth after previous caesarean birth, Green top Guideline. No.45, 2007p1-17.
25. RCOG Green top Guideline No-42 Nov 2014 page 6-9
26. Essential Obstetric and Newborn Care, Lifesaving skills manual, RCOG in partnership with LSTM, WHO, LATH
27. Ipas, VSI, Misoprostol use in post abortion care : A service delivery Tool kit chapel, Hill, Ipas, 2011: 47-48
28. WHO - Safe abortion: Technical and policy guidance for health systems - 2nd edition, Geneva: WHO
29. OGSB - Blue TOP guideline - Standard clinical management prototcols and guidelines September 2012
30. Misoprostol Only Recommended Regimens 2017. FOGO; www.figo. org
31. FIGO oncology committee. FIGO staging for gestational trophoblastic neoplasia 2000. FIGO oncology committee. Int J Gynaecol Obstet. 2002 Jun;
77 (3):285-7.
32. Mangili G, Lorusso D, Brown J, PfistererJ, Massuger L, Vaughan M, et al. Trophoblastic diseases review for Diagnosis and Management: A Joint Report
From the International Society for the Study of Trophoblastic disease, European Organization for the Treatment of Trophoblastic Diease, and the
Gynaecologic Cancer Inter Group. Int J Gynecol Cancer.2014 Nov;24(9Suppl3): s109-16.
33. Bolze P-A, Attia J, Massardier J, Seckl MJ, Massuger L, van Trommel N, et al. Formalised consensus of the European Organisation for Treatment of
Trophoblastic Diseases on management of gestotional trophoblastic diseases. Eur J Cancer. Elsevier Ltd; 2015 Sep. 1;51(13): 1725-31.
34. Bleeding and/or pain in early pregnancy patient information-RCOG;
https:// www.rcog.org.uk/en/patients/patient../bleeding-and-pain-in-early-pregnancy/Sep 21, 2016
35. Management of pregnancy of unknown location (PUL);
https://www.nuh.nhs.uk/handlers/downloads.ashx?id=6118Emergency Gynecology SSU_S.Deb Guidelines on Management of PUL
36. Technical standard & service delivery guideline: Post Abortion Care DGFP, MOHFW and Engender health
37. Clinical Practice Guideline SOGC , No 247 , 2017
38. WHO recommendations Intrapartum care for a positive childbirth experience 2018
39. Infection prevention practices Standard and Guideline Directorate General of Health Services, Ministry of health and Family Welfare 2003
40. If tap water is contaminated, use water that has been boiled for 10 minutes and filtered to remove particulate matter (if necessary), or use chlorinated water—
water treated with a dilute bleach solution (sodium hypochlorite) to make the finalconcentration 0.001%
41. Pereira LJ, GM Lee and KJ Wade. 1997. An evaluation of five protocols for surgical handwashing in relatin to skin condition and microbial counts, J Hosp
Infect 36(I):49-65.
42. Pereira LJ, GM Lee and KJ Wade. 1990. The effects of surgical handwashing routines on the microbial counts of operating room nurses. Am J Infect Control
18(6):354-364.
43. National Institute for Occupational Safety and Health, Department of Health and Human Services (NIOSH). 1997. NIOSH Alert; Preventing Allergic Reaction
to Nature Ruber Latex in the Workplace. No. 97:135.

130 STANDARD CLINICAL MANAGEMENT PROTOCOLS AND FLOWCHARTS ON

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Standard Management Protocol on EmONC

Core Committee
Prof. Laila Arjumand Banu, President-OGSB
Prof. Firoza Begum, Secretary General-OGSB
Prof. TA Chowdhury, Past President-OGSB
Prof. Shahla Khatun-Past President-OGSB
Prof. Latifa Shamsuddin, Past President-OGSB
Prof. Anowara Begum, Past President-OGSB
Prof. Kohinoor Begum, Past President-OGSB
Prof. Rowshan Ara Begum, Immediate Past President-OGSB
Prof. Sameena Chowdhury, President Elect-OGSB
Prof. Fatema Ashraf, Head, ShaheedSuhrawardi MC

Working Group Committee (WGC)

Prof. Sayeba Akhter, Past President-OGSB
Prof. Sabera Khatun, Professor of Gynae Oncology, BSMMU
Prof. Ferdousi Begum, Head of the dept. of Obs&Gynae, BIRDEM
Prof. Nazneen Kabir, Ex Executive Director-ICMH
Prof. Farhana Dewan, Head of the dept. of Obs&Gynae, IbnSina Medical College
Prof. Salma Rouf, Head of the dept. of Obs&Gynae, DMC
Prof. Nahreen Akhter, Professor of Feto-maternal Medicine-BSMMU
Prof. SkZinnat Ara Nasreen, Head of the dept. of Obs&Gynae, Sikder Medical College
Prof. Kishwar Sultana, Professor of Obs&Gynae, HFRCMCH
Dr. Tabassum Parveen, Assoc. Prof. of Feto-maternal Medicine-BSMMU
Dr. Afroza Kutubi, Assoc. Prof. of Obs&Gynae, DMCH
Dr. Alpona Adhikari, Asstt. Prof. of Obs&Gynae, ShSMC
Prof. Ratu Rumana Binte Rahman, Prof. of Obs&Gynae, SSMCH
Dr. Dilder Ahmed Khan, Neonatologist

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 List of Reviewers and Contributors
1. Prof. Laila Arjumand Banu, President, OGSB
2. Prof. Firoza Begum, Secretary General, OGSB
3. National Prof. Shahla Khatun, Past President, OGSB
4. Prof. Rowshan Ara Begum, Immediate Past President, OGSB
5. Prof. Sameena Chowdhury, President Elect, OGSB
6. Prof. Kohinoor Begum , Past President, OGSB
7. Prof. Sayeba Akhter, Past President, OGSB
8. Prof. Latifa Shamsuddin, Past President, OGSB
9. Prof. Anowara Begum, Past President, OGSB
10. Prof. Nahreen Akhtar, Professor of Fetomaternal Medicine-BSMMU
11. Prof. Farhana Dewan, Head of the dept. of Obs&Gynae, IbnSina Medical College
12. Prof. SariaTasnim, Ex Executive Director, ICMH
13. Prof. Parveen Fatima, Chairman, Obs & Gynae, BSMMU
14. Prof. Sabera Khatun, Professor of Gynae Oncology, BSMMU
15. Prof. Ferdousi Begum, Head of the dept. of Obs & Gynae, BIRDEM
16. Prof. Nazneen Kabir, Ex Executive Director-ICMH
17. Prof. Salma Rouf, Head of the dept. of Obs&Gynae, DMCH
18. Prof. Sk Zinnat Ara Nasreen, Head of the dept. of Obs & Gynae, Sikder Medical College
19. Prof. Fatema Ashraf, Head, Dept. of Obs&Gynae, ShSMCH
20. Dr. Tabassum Parveen, Assoc. Prof. of Feto-maternal Medicine-BSMMU
21. Prof. Jannatul Ferdous, Gynae Oncology, BSMMU
22. Prof. Shahin Rahman Chowdhury, Head, HFRCMC
23. Prof. Kishwar Sultana, Professor of Obs & Gynae, HFRCMCH
24. Dr. S.M Shamsuzzaman, Line Director, MNC & AH, DGHS
25. Dr. Mohammed Sharif, Director, MCH Service and Line Director, MCRAH, DGFP
26. Dr. K.M Azad, PM, Qoc4, Ad (Hospital), DGHS
27. Dr. Nasima Khatun, DPM-Monitoring, MH, DGHS
28. Dr. Fahmida Sultana, DD & PM (MCH), DGFP
29. Prof. Ratu Rumana Binte Rahman, Prof. of Obs & Gynae, SSMCH
30. Dr. Afroza Kutubi, Assoc. Prof. of Obs & Gynae, DMCH
31. Prof. MA Mannan, Chairman, Neonetology, BSMMU
32. Dr. Dilder Ahmed Khan, Neonatalogtist
33. Dr. Alpana Adhikari, Assoc. Prof. ShSMCH
34. Dr. Fahmida ShaminJoty, Asst. Prof. Care MCH
35. Dr. Syeda Sayeeda, Assoc. Prof. BSMMU
36. Dr. Mahbuba Khan, NPO-MPS program, WHO
37. Dr. Ziaul Matin, Health Manager, UNICEF
38. Dr. ASM Sayem, Maternal Health Specialist, UNICEF
39. Dr. Farhana Shams Shumi, Health Officer, UNICEF
40. Rondi Anderson, International Midwifery Specialist, UNFPA Bangladesh
41. Dr. Sharif Md. Ismail Hossain, Associate, Population Council
42. Dr. Setara Rahman Program Director-MCHIP, Jhpiego/Save the Children in Bangladesh
43. Dr. Shamila Nahar, Sr. Advisor, Health, Ipas, Bangladesh

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134 STANDARD CLINICAL MANAGEMENT PROTOCOLS AND FLOWCHARTS ON
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