1

TABLE OF CONTENTS Page

Introduction 3
List of abbreviations 5

Chapter 1: Antenatal care 7

Objectives of antenatal care 7

Antenatal Clinic 7
The first antenatal visit 7
Information for pregnant women 14
Subsequent and referral antenatal visits 15
Assessment of fetal well being 16
Management of common antenatal problems 18

Chapter 2: Labour, delivery and puerperium 22

Diagnosis of labour 22
Admission of a woman in labour 22
General care of women in labour 24
Routine monitoring of the first stage of labour 25
The partogram: alert and action lines 25
Analgesia in labour 26
Fetal monitoring 26
The second stage of labour 28
The third stage of labour 29
The fourth stage of labour 29
Home delivery – ‘born before arrival’ 31
Abnormalities of the first stage of labour 32
Emergencies during labour and prolonged second stage 36
Instrumental delivery 39
Caesarean section 41
Immediate care of the newborn 44
Abnormalities of the third and fourth stages of labour 48
Primary postpartum haemorrhage 50
Cardiopulmonary resuscitation (CPR) in pregnancy 54
The unconscious obstetric patient 57
The normal puerperium 58
Secondary postpartum haemorrhage 58
Puerperal sepsis 59
Lactation and lactation suppression 62

Chapter 3: Hypertension in pregnancy 64

Definitions 64
Pathophysiology of pre-eclampsia 66
Management of hypertensive disorders of pregnancy 67
Labour and delivery in hypertensive disorders 73
Postpartum care 73
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Chapter 4: Common obstetric problems 74

Intrauterine growth restriction 74
Intrauterine death 77
Antepartum haemorrhage 78
Multiple pregnancy 84
Breech presentation and transverse lie 87
Preterm labour 89
Prelabour rupture of the membranes 92
Chorioamnionitis 94
Suspected prolonged pregnancy 94
Induction of labour with a live baby 95
Rhesus incompatibility 98
Previous caesarean section 98
Poor obstetric history 100

Chapter 5: Fetal medicine 103

The Fetal Medicine Unit 103
The ultrasound scan at 11-14 weeks 103
The ultrasound scan at 18-23 weeks 104
Women for referral to the Fetal Medicine Unit 105
Postnatal investigation 106

Chapter 6: Medical disorders 108

Anaemia and transfusion 108
Diabetes mellitus 112
Thyroid disease 117
Cardiac disease 118
Anticoagulation 120
Thromboembolic disease 122
Asthma 123
Jaundice 125
Epilepsy 126

Chapter 7: Infectious conditions 127

Sexually transmitted infections 127
HIV infection in pregnancy 129
Group B streptococcal infection 136
Urinary tract infection 136
Pneumonia and tuberculosis 137
Malaria 140

Chapter 8: Terminology, audit and statistics 142

Audit 144
Essential statistics 144
Perinatal deaths 145
Maternal deaths 146
Audit meetings 147
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Wits Obstetrics 2017

Early release edition
Introduction

This guidelines book is an update of the 2013 ‘Wits Obstetrics’ obstetric clinical
guidelines for the Department of Obstetrics and Gynaecology at the University of
the University of the Witwatersrand, originally the ‘Obstetrical Handbook for
Doctors’ produced in 1998, rewritten in 2003, and updated in 2007 as ‘CHB
Obstetrics’ for Chris Hani Baragwanath Hospital. This edition has the same
format, with much of the content aligned with the national Department of Health’s
Guidelines for Maternity Care in South Africa. The content applies in general to
the three referral hospitals attached to the Wits academic department – Charlotte
Maxeke Johannesburg Academic Hospital, Rahima Moosa Mother and Child
Hospital, and Chris Hani Baragwanath Academic Hospital. The booklet may have
value in other Johannesburg and Gauteng Province hospitals, and also in
hospitals elsewhere in South Africa.

The guidelines recommend management of common obstetric conditions at

primary and referral level, based on local experience and evidence-based
practice. They are not intended as strict protocols nor as standard operating
procedures, but rather as a guide to safe effective management of common
obstetric problems. The guidelines should be most useful to interns, medical
officers and registrars.

A special thank you to the following people who participated in reviewing the
book, and made valuable contributions toward its improvement:

Prof Y Adam
Dr S Bhoora
Dr M Bothma
Dr L Chauke
Dr A Chrysostomou
Dr W Edridge
Dr J Jeebodh
Prof H Lombaard
Dr S Maswime
Dr C Mnyani
Prof E Nicolaou
Dr R Nyakoe
Dr N Pirani
Dr H Rhemtula
Dr A Wise
 4

Our eternal gratitude to Prof Eckhart Buchmann, the past editor, for his continued
support and contributions.

Ebrahim Bera (editor)

Department of Obstetrics and Gynaecology
School of Clinical Medicine
Faculty of Health Sciences
University of the Witwatersrand
Johannesburg

16 November 2016
 5

LIST OF ABBREVIATIONS

3TC – lamivudine
AB – asymptomatic bacteriuria
ABC – abacavir
ABG – arterial blood gas
AIDS – acquired immune deficiency syndrome
APH – antepartum haemorrhage
APHUO – antepartum haemorrhage of unknown origin
APS – antiphospholipid syndrome
ALT – alanine transaminase
ART – antiretroviral therapy
ARV – antiretroviral
AST – aspartate transaminase
AVPU – alert, voice, pain, unresponsive
AZT – zidovudine
BMV – bag-mask ventilation
CPR – cardiopulmonary resuscitation
CS – caesarean section
CSF – cerebrospinal fluid
CT – computerized tomography
CTG – cardiotocograph
CVP – central venous pressure
CVS – chorionic villus sampling (biopsy)
DVT – deep vein thrombosis
ECG - electrocardiograph
ECV – external cephalic version
EDD – expected date of delivery
EFV – efavirenz
FBC – full blood count
FDC – fixed dose combination
FTC – emtricitabine
GCS – Glasgow Coma Scale
Hb – haemoglobin
HbA1C – glycated haemoglobin
hCG – human chorionic gonadotrophin
HCT – HIV counseling and testing
HIV – human immunodeficiency virus
HR – heart rate
ICS – inhaled corticosteroids
ICU – intensive care unit
IO – intra-osseous
IM – intramuscular
INR – international normalized ratio
 6

LIST OF ABBREVIATIONS (contd)

IUFD – intrauterine fetal death

IUGR – intrauterine growth restriction
IV – intravenous
LFT – liver function tests
LMP – last menstrual period
LPV/r – lopinavir/ritonavir
M&M – morbidity and mortality
MA – maternal age
MCA – middle cerebral artery
MCS – microscopy, culture and sensitivity
MCV – mean cell volume
MOU – midwife obstetric unit
MSU – midstream urine
MUAC – mid-upper arm circumference
NB – nasal bone
NCCEMD – National Committee on Confidential Enquiries into Maternal Deaths
NST – non-stress test
NT – nuchal translucency
NVP – nevirapine
NYHA – New York Heart Association
OGTT – oral glucose tolerance test
PAPP-A – pregnancy-associated placental protein A
PCR – polymerase chain reaction
PE – pulmonary embolism
PMTCT – prevention of mother-to-child transmission
PPH – postpartum haemorrhage
PTT – partial thromboplastin time
RHZE – rifampicin, isoniazid, pyrazinamide, ethambutol
RPR – rapid plasma regain
RPV – rilpivarine
SC – subcutaneous
SFH – symphysis-fundal height
TB - tuberculosis
TDF – tenofovir
TOP – termination of pregnancy
U&E – urea and electrolytes
VBAC – vaginal birth after caesarean section
VF – ventricular fibrillation
VT – ventricular tachycardia
VL – viral load
 7

Chapter 1 Antenatal Care

OBJECTIVES OF ANTENATAL CARE

Antenatal care attempts to ensure, by antenatal preparation, the best possible

pregnancy outcome for women and their babies. This may be achieved by:

 Screening for pregnancy problems

 Assessment of pregnancy risk – high or low risk
 Management of problems that may arise during the antenatal period
 Medication that may improve pregnancy outcome
 Information given to pregnant women
 Physical and psychological preparation for childbirth and parenthood

ANTENATAL CLINIC

Ideally, only high risk pregnancies and midwife referrals should be managed at
hospitals. Women without risk factors are best seen at midwife-run clinics from
which they can be referred if necessary. Where a hospital manages low risk
pregnant women, these should be separated from the high risk group and be
seen by midwives. A list of high risk conditions is given on pages 20 and 21.

THE ANTENATAL RECORD

This fold-up card, or the relevant pages in the national maternity file, is the
essential record of the pregnancy and must be completed at each antenatal clinic
visit and retained by the pregnant woman until delivery. Women who present with
a card from another province should have that card completed at the clinic, rather
than be issued with a new card which would duplicate or mask information from
earlier in the pregnancy. The content of antenatal cards may vary between
provinces, but most formats are adequate for essential antenatal care.

THE FIRST ANTENATAL VISIT

Pregnant women should book for antenatal care as soon as pregnancy is

detected, even as early as 5-6 weeks’ gestation.

Make a complete assessment of gestational age and risk factors at the first
antenatal visit. It is not necessary to wait until the second visit before such
assessments are finalized. After one visit, a pregnant woman can be regarded
as ‘booked’.
 8

HISTORY TAKING

This follows the check-list on the antenatal record

 Gestational age – last menstrual period, cycle regularity and previous

contraception
 Current pregnancy, especially last menstrual period
 Previous pregnancies, any complications and outcomes
 Medical conditions, previous surgery, and psychiatric problems
 Familial and genetic disorders, also considering ethnic origin, e.g sickle cell
 Allergies
 Use of medications,
 Use of alcohol, tobacco and other substances
 Family and social circumstances
 Plans for contraception after the pregnancy

SCREENING TO DETECT TUBERCULOSIS (TB)

All women infected with human immunodeficiency virus (HIV) should be asked if
they have experienced the following symptoms:

 Cough for two weeks

 Fever
 Drenching night sweats
 Weight loss

Women with any one or more of these symptoms should provide sputum for TB
testing and be followed up, and/or be further investigated.

PHYSICAL EXAMINATION

 General examination, including weight, heart rate, colour of mucous

membranes, mid-upper arm circumference (MUAC), blood pressure (BP), and
a check for oedema.

 Systemic examination, including teeth and gums, breasts, thyroid, and heart

 Pregnancy examination, including inspection and palpation of the pregnant

uterus, with measurement of the symphysis-fundal height (SFH) in cm, and
systematic palpation using Leopold’s method – fundal, lateral, Pawlik and
pelvic grips
 9

ESTIMATION OF GESTATIONAL AGE

Indicate clearly on the antenatal card (top left above the symphysis-fundal height
graph how the gestational age was estimated. The first estimation of gestational
age, with the expected date of delivery, will be used for the remainder of the
pregnancy and must not be changed unless important new information becomes
available.

Ultrasound

This is extremely useful for measuring gestational age. An ultrasound scan at

24 weeks is an accurate indicator of gestation, and overrides other methods of
gestational age estimation. An ultrasound estimate of >24 weeks is less reliable
but is still useful when there is uncertainty about the date of a woman’s last
menstrual period.

Last menstrual period (LMP)

This is valid if the woman is sure of her dates, and where palpation of the uterus
and SFH measurement are compatible with the given dates. Use Naegele’s rule:
Expected date of delivery (EDD) = first day of last menstrual period plus 7 days,
minus 3 months, plus 1 year.
Example: If LMP is on 5 October 2016, EDD will be on 12 July 2017.

Symphysis-fundal height (SFH) measurement

This is used if the dates from the last menstrual period are unknown or wrong,
and if there is no ultrasound estimation of gestational age, provided that the
pregnancy is otherwise normal. The measured SFH is plotted onto the 50 th
centile line on the SFH graph, allowing the corresponding gestational age to be
read from the graph. Examples are shown on pages 11, 12 & 13.

Palpation

The SFH measurement is of little value at <20 cm (corresponding to <20 weeks).

In early pregnancy, bimanual and abdominal palpation can be used. At term,
palpation of the fetal head may be helpful. Gestational age assessment by
palpation requires care, skill and experience.
 10

SCREENING INVESTIGATIONS

The following are offered as routine:

 Syphilis serology (RPR)

 Rhesus (D) blood group, using a rapid card test
 Haemoglobin (Hb) level
 HIV serology, following principles of HIV counselling and testing (HCT). A
rapid test is done, with confirmation of positive results using a different kit.
Post-test counselling follows immediately. A CD4 cell count is done on all
women who test HIV positive
 Urine dipstick for protein and glucose
 Ultrasound scan for any woman presenting at ≤24 weeks
 Nuchal translucency and uterine artery Doppler screening (from 11-14 weeks)
may be offered to women sent for scan at ≤14 weeks

All of the above tests should ideally be performed at the antenatal clinic, with the
results available to the pregnant women before they complete their first visits.

MEDICATIONS

The following are given to all pregnant women:

 Ferrous sulphate 170 mg daily, OR Ferrous fumarate 200 mg daily

 Folic acid 5 mg daily
 Elemental calcium 1 g daily in divided doses

FINAL ASSESSMENT

The final assessment should include:

 A problem list in the appropriate space on the antenatal card

 A note on how the problems should be managed further
 The next follow-up date entered on the symphysis-fundal height graph
corresponding the gestational age at that visit
 A delivery plan: the estimated date, and the planned place and mode of
delivery
 11

SFH graph of a woman with correct menstrual dates. At booking (27/5/13), she is 22
weeks pregnant by dates. The SFH is 20 cm, in keeping with her dates. Subsequently,
SFH growth is normal, between the 10th (lower dotted line) and 50th centile (solid line).
 12

SFH graph of a woman whose menstrual dates are unknown. At booking (5/8/13),
the SFH of 28 cm is entered on the 50th centile line, giving a gestational age of 29
weeks. At subsequent visits, SFH growth is above the 50th centile line, but is normal as it
has not crossed above the 90th centile line (the upper dotted line).
 13

SFH graph of a woman with abnormal SFH growth. At 34 weeks of gestation, the
SFH measurement has crossed to below the 10th centile. Possible reasons include 1)
intrauterine growth restriction; 2) olighydramnios; and 3) fetal death, each possibly linked
to pre-eclampsia (BP 140/90 mmHg with +proteinuria). These findings necessitate
ultrasound scanning, and if the fetus is alive, assessment of amniotic fluid volume, fetal
biometry and umbilical artery Doppler studies, and hospital admission.
 14

INFORMATION FOR PREGNANT WOMEN

Certain essential information must be provided to all pregnant women, verbally or

in the form of written or illustrated cards or pamphlets. Midwives provide much of
this information, but doctors may need to emphasize some of these points.

1. Five danger signs and symptoms of pregnancy

 Severe headache
 Abdominal pain (not discomfort)
 Drainage of amniotic fluid (liquor) from the vagina
 Vaginal bleeding
 Reduced fetal movements

A woman that experiences any of these symptoms should report immediately to

her clinic or hospital with her antenatal card.

2. Self-care in pregnancy

 Diet, exercise, sexual intercourse and safe sex, travel, work, etc.
 Personal hygiene and breast care
 Use of medications
 Avoidance of alcohol, tobacco and recreational drugs
 Avoidance of traditional medicines such as isihlambezo (a uterotonic)

3. A delivery plan

At the end of their first visit, all pregnant women should be given a provisional
delivery plan:

 The expected date of delivery, based on the best estimate of gestational age
 The expected place of delivery, whether community health centre or hospital
 The expected mode of delivery, whether vaginal or caesarean section
 Who will deliver the baby, whether midwife or doctor

4. Newborn and infant care

 Plans for infant feeding and techniques, whether breast or formula

 Details of follow up care: immunization and where this can be obtained

5. Future pregnancies and contraception

 Contraception that will be used after the pregnancy

 Return to normal activities e.g. work, sexual intercourse
 15

SUBSEQUENT AND REFERRAL ANTENATAL VISITS

SCHEDULE FOR RETURN VISITS

The schedule shown provides a framework for visits for women attending at the
hospital antenatal clinic. More frequent visits may be appropriate for certain high
risk women.

Minimum schedule for return antenatal visits at hospital

Gestational age at current visit Scheduled return visit

(weeks)

6-19 24 weeks

20-25 28 weeks

26-28 30 weeks

29-39 After 2 weeks

40 41 weeks

CONTENT OF VISITS

 If the woman is referred from a clinic, be sure to know the reason for referral
 Ask about general health, fetal movements, danger symptoms, and problems
 For HIV infected women, ask the four screening questions for TB. Also,
ensure that all aspects of HIV care are in order (CD4 testing and drugs)
 Check the BP, heart rate and colour of the mucous membranes
 Measure the SFH in cm, and palpate the pregnant uterus. Consider the
possibility of breech presentation and twin pregnancy in all women ≥34
weeks. Plot the SFH on the graph against the gestational age and interpret
this in accordance with the centile lines and previous measurements. Send
for ultrasound scan if necessary
 Check urine test results for protein and glucose
 Repeat blood tests: Hb at 32 and 36 weeks, and HIV every 3 months
 Where appropriate, repeat information for pregnant women as for the first visit
 If the problem related to a clinic referral is resolved, tell the woman to return
to her local clinic for the next visit and give her an appropriate date. Write
clear notes on the antenatal record to assist the midwives at the woman’s
local clinic.
 16

ASSESSMENT OF FETAL WELL BEING

ULTRASOUND SCANS

Ultrasound scans are done only for certain clinical indications.

 Women who book at ≤24 weeks at the hospital (high risk conditions)
 Doubt about gestational age after clinical assessment, e.g. wrong dates, or
possible twin pregnancy, suspected intrauterine growth restriction (IUGR)
 Fetal movements not felt and fetal heart not heard, at ≥22 weeks
 Significant risk for IUGR (e.g. hypertensive) or macrosomia (e.g. diabetic)
 Previous or family history of congenital abnormalities
 Poor obstetric history (two or more previous pregnancy losses)
 History of antepartum haemorrhage
 Malpresentation, from 36 weeks
 Two or more previous caesarean sections
 Doubt about post-term pregnancy, to measure amniotic fluid volume

NON-STRESS TESTS

Very few antenatal women require a non-stress test (NST). Indications include:

 Reduced fetal movements at any time after 28 weeks

 Previous unexplained stillbirth at term: weekly from 36 weeks
 Conditions where the fetus is considered to be at risk, e.g. diabetes mellitus
after 36 weeks, suspected IUGR or suspected post-term pregnancy
 Antepartum bleeding

There is no indication for routine NST at 39-40 weeks

FETAL MOVEMENT COUNTING

This is only indicated for high risk pregnancies, e.g. diabetes mellitus, suspected
IUGR, previous unexplained stillbirth.

1. Ask the woman to count fetal movements (not just kicks) for one hour at the
same time every day, usually after breakfast
2. The number of movements should be recorded on a fetal movement chart
3. If there are 4 or more movements in one hour, the count is repeated at the
same time on the next day
4. If there are less than 4 movements in one hour, or less than half of the hourly
average (after about a week of counting), the woman should count fetal
movements for one more hour
5. In the second hour, if there are still less than 4 movements or less than half of
the hourly average, NST is indicated to assess fetal well-being. Delivery may
be necessary
 17

Fetal movement chart

Date Time Movements N.B. Movements N.B.

Started in first hour in second
hour
If <4 move- If <4 move-
ments in the ments in
first hour go on the second
to the second hour please
hour and count go to your
again clinic or
hospital for
help
 18

MANAGEMENT OF COMMON ANTENATAL PROBLEMS

Proteinuria
Proteinuria + or more should raise suspicions of pre-eclampsia or urinary tract
infection. Check the BP again and ask for repeat testing of a mid-stream urine
(MSU) specimen. A high BP in the presence of proteinuria indicates pre-
eclampsia, and necessitates hospital admission. If the BP is normal and
proteinuria is confirmed, ask the woman if she has symptoms of urinary tract
infection and send an MSU specimen to the laboratory for MCS (microscopy,
culture and sensitivity). Follow up for results in one week.

Vomiting
Exclude any illness (e.g. appendicitis, hepatitis, pyelonephritis) that may cause
vomiting. Mild vomiting in a healthy woman requires no more than reassurance,
dietary advice (avoidance of large or very fatty meals), and, if necessary,
metoclopramide 10 mg orally 8 hourly when necessary. Vomiting that follows all
meals or drinks and causes dehydration (hyperemesis gravidarum) requires
hospital admission for investigation, intravenous fluids and anti-emetic therapy.

Heartburn
Heartburn is a very common symptom in pregnancy. Advise on avoiding large
and fatty meals. Prescribe available antacid, e.g. aluminium hydroxide 10-20 mL,
calcium carbonate or magnesium trisilicate 1 to 2 tablets orally when necessary.

Constipation
Reassure the woman that mild constipation is normal in pregnancy, discourage
the use of laxatives, and recommend a high intake of fibre and fluid. If a laxative
is required, suggest using natural bran, or prescribe bulk-forming laxatives such
as Ispaghula husk. Alternatively lactulose 10 mL 12 hourly may be prescribed. It
is best not to prescribe irritants (e.g. senna, bisacodyl) in pregnancy.

Haemorrhoids
Distended veins around the anus are frequent in pregnancy. Suggest measures
to prevent constipation and discourage straining at stool. If the haemorrhoids are
asymptomatic, reassure but explain that they will persist at least until the
pregnancy is completed. Mild pain from thrombosed haemorrhoids can be
managed with local anaesthetic creams. Refer severe and difficult cases for
surgical opinion.

Urinary incontinence
Mild stress urinary incontinence may occur for the first time in pregnancy.
Exclude urinary tract infection by performing dipstick testing and/or sending urine
for MCS. Teach pelvic floor (Kegel’s) exercises – squeezing for 3 seconds and
releasing for 10, repeated 10 times. This is done 10 times per day.
 19

Striae gravidarum
There are no creams or medications that are known to be effective in preventing
striae gravidarum.

Varicose veins
Reassurance and advice on leg elevation may be sufficient. Treat troublesome
varicose veins by prescribing elastic stockings.

Nonspecific aches and pains

Try to establish a cause for the pain and advise on adjustments in work and
lifestyle. Common causes of pain include low backache, sacroiliac strain, round
ligament pain, symphysis pubis pain, painful knees and painful ankles. Prescribe
paracetamol 1 g orally when necessary. Sleeping with a pillow between the legs
may relieve low backache.

Leg cramps
No specific measures have been proven to prevent cramps. Light exercise and
stretching may be of value.

Skin rash
Always consider chickenpox, herpes zoster and syphilis as causes. Seek
consultant advice and refer to a dermatologist if necessary. There are a number
of pregnancy-specific rashes – polymorphic eruption of pregnancy, popular
eruption of pregnancy, pemphigoid gestationis and impetigo herpetiformis.
Intrahepatic cholestasis of pregnancy (causing pruritus) is a very rare condition in
South Africa.

Domestic violence
This is defined as intentional abuse inflicted on one partner by another in an
intimate relationship. This may be physical, psychological or sexual. Pregnant
women are at increased risk for undergoing such abuse. Women at particular risk
for intimate partner violence may have unwanted or unplanned gestations, or be
unbooked or book late in pregnancy (third trimester).

It may be worthwhile to ask women privately if all is well at home and if they are
getting all the support they need from their partners. Enquire tactfully about
domestic circumstances in women who present frequently with unexplained
symptoms or who have multiple trivial injuries. Where domestic violence is
reported, the woman must be appropriately counseled and referred to the social
work department.
 20

LIST OF PRE-EXISTING ANTENATAL RISK FACTORS

High risk (antenatal care and delivery at hospital)

Primigravida aged 35 years or older

Previous infertility treatment
Previous myomectomy
Previous cervical or vaginal surgery, including cerclage
Previous surgery for urinary incontinence
Previous hysterotomy or classical caesarean section
Previous stillbirth or early neonatal death
Previous baby with obstetric related cerebral palsy
Risk of genetic problems (in women booking at ≤24 weeks)*
Last baby preterm delivery at 7 months or less*
Last pregnancy severe pre-eclampsia*
Three or more previous miscarriages*
Two or more mid-trimester miscarriages*
Diabetes mellitus
Chronic hypertension or renal disease
Currently symptomatic asthma
Epilepsy on treatment
Active tuberculosis
Malignant disease, e.g. cervix, breast
Heart disease
Autoimmune disease, e.g. lupus
History of venous thrombo-embolism
Psychiatric illness, including previous postpartum depression or psychosis
Thyroid disease or thyroidectomy
Serious disease or deformity of the spine, pelvis or hip, and paraplegia
Any other serious medical condition

*These risk factors may fall away as pregnancy advances

Intermediate risk (antenatal care at local clinic, delivery at hospital)

Previous postpartum haemorrhage requiring blood transfusion

Previous lower segment caesarean section†
Short stature (<1.5 m)
Parity 5

†Women with previous caesarean section should be seen at least once by an

obstetric doctor during antenatal care, preferably early in the pregnancy
 21

LIST OF RISK FACTORS THAT ARISE DURING ANTENATAL CARE

Requiring non-urgent referral

Anaemia (see Chapter 6: Medical Disorders)

Uterus large for dates (>90th centile symphysis-fundal height)
Uterus small for dates (<10th centile symphysis-fundal height)
Symphysis-fundal height decreasing
No maternal weight gain in a woman <60 kg
Known or suspected multiple pregnancy
Breech or transverse lie at 36 weeks or more
Rhesus negative blood group with antibodies
Extensive vulval warts that may obstruct vaginal delivery
Pregnancy at 41 weeks or more
Abnormal glucose tolerance test
Mild hypertension without proteinuria

Requiring urgent (same day) referral

Reduced fetal movements at 28 weeks or more

Pre-eclampsia
Severe non-proteinuric hypertension (≥160/110 mmHg)
Antepartum haemorrhage
Prelabour rupture of the membranes
Any obstetric emergency
Any severe illness, e.g. with pyrexia, shortness of breath or abdominal pain

Many of the above categories of patients may be sent back to their local clinics
for further antenatal care if their problems are resolved at (examples: suspected
breech presentation at term found to be cephalic, or suspected IUGR found to be
wrong dates)
 22

Chapter 2 Labour, delivery and puerperium

DIAGNOSIS OF LABOUR

Labour is diagnosed if there are painful regular uterine contractions accompanied

by at least one of the following:

 Cervical effacement and dilatation

 Rupture of the membranes
 Show

The latent phase is defined as labour with the cervix dilated 3 cm or less, not
fully effaced. The active phase is defined as labour with the cervix dilated ≥4 cm
and fully effaced. This distinction may at times be difficult.

ADMISSION OF A WOMAN IN LABOUR

Enter all relevant clinical findings in the maternity file, and enter labour findings
on the partogram if the woman is in the active phase of labour.

HISTORY TAKING

1. Carefully review the antenatal card. Clearly note all risk factors. Interview
unbooked women as if they were attending antenatal clinic for the first time

2. Note the nature of labour pains, vaginal bleeding, fetal movements, passage
of liquor and any other relevant symptoms

PHYSICAL EXAMINATION

1. General examination includes psychological state, heart rate, temperature,

BP, oedema and pallor

2. Abdominal examination:

 Inspection
 SFH in cm
 Lie, presentation, position, and attitude
 Level of the presenting part in fifths above the pelvic brim
 Uterine tone, and strength and frequency of contractions
 Auscultation of the fetal heart rate between, during and after contractions
 Estimation of fetal weight
 23

3. Vaginal examination:

 Vulva and vagina: abnormal discharge, warts or sores

 Cervix: length (effacement), position, consistency, and dilatation in cm
 Membranes: ruptured or not
 Liquor, if the membranes have ruptured: meconium staining and grade
 The presenting part: its position, the degree of moulding and caput
 Station in relation to the ischial spines (this does not replace careful
abdominal assessment of descent of the head in fifths)

SPECIAL INVESTIGATIONS

1. Test the urine for glucose, protein and ketones

2. Take blood for RPR and rhesus group in unbooked women and in those
whose results are not available. Offer HIV testing after appropriate pre-test
counseling
3. Measure Hb level, or repeat the test if the last Hb was done >4 weeks ago.
A ward haemoglobinometer result is acceptable

CARDIOTOCOGRAPHY (CTG) ON ADMISSION

Ideally, women who present to a referral hospital in labour should have specific
risk factors, and need continuous CTG in labour. Run an admission tracing for 20
minutes, to screen for abnormalities before transferring the woman to labour
ward. Self-referred low-risk women do not require CTG monitoring. Intermittent
auscultation using a hand-held Doppler instrument or a fetal stethoscope should
be used for women not on CTG.

WOMEN TRANSFERRED FROM CLINICS AND OTHER HOSPITALS

These women need careful attention on admission, as they are being transferred
for a problem or risk factor. The most common reasons for transfer are poor
labour progress, hypertension, and suspected fetal distress (fetal heart rate
abnormalities or thick meconium staining of the liquor). Carefully read the notes
from the clinic and assess the progress of labour from the time the woman first
presented.

Enter progress on the partogram from the clinic, not on a new partogram.
 24

GENERAL CARE OF WOMEN IN LABOUR

1. Low risk women who present to hospitals in labour

Many women present in labour at hospitals even though they have no risk factors
to qualify for hospital delivery. Such women, if not in advanced labour (cervix ≤6
cm dilated) may be transferred to a local midwife obstetric unit if a ‘triage’ system
exists, with ambulance or planned patient transport available.

2. Respect, privacy and companionship

Treat all women in labour with respect and courtesy. Ensure privacy and always
perform intimate examinations behind screens or curtains. Each woman should
be allowed one visitor to provide companionship during labour, subject to the
discretion of the midwife in charge of the labour ward.

3. Diet and fluids

Low risk women can be allowed to eat and drink during labour. An intravenous
infusion is not needed. In general, high risk women should not eat in the active
phase of labour, but may drink clear fluids. High risk women usually require an
intravenous infusion of Ringer-Lactate solution to run at 120 mL/hour, or 70
mL/hour with cardiac disease or hypertension.

4. Keeping the bladder empty

A full bladder interferes with the efficiency of uterine contractions. Be ready to
assist women to go to the toilet or use a bedpan. If necessary, pass a urinary
catheter to empty the bladder.

5. Posture
Encourage women to walk around in the latent phase of labour, and in the early
stages of the active phase of labour if possible. Any posture (sitting, standing,
kneeling, lying) is acceptable in both phases of the first stage of labour except
the flat supine position which causes aortocaval compression by the pregnant
uterus.

6. Artificial rupture of the membranes (amniotomy)

This procedure is not necessary in the routine management of normal labour,
and is contraindicated in HIV-infected women with elevated plasma viral load
(VL), unless the expected clinical benefit (better labour progress) is greater than
the perceived increased risk of mother-to-child transmission of HIV.

7. Partogram
In the active phase of labour, all clinical observations must be entered on the
partogram. If an adequate entry has been made on the partogram, there is no
need to make duplicate written notes. Examples are shown on pages 27, 33 and
34. A clinical assessment and plan should however be written separately in the
notes after each labour progress examination.
 25

ROUTINE MONITORING OF THE FIRST STAGE OF LABOUR

Latent phase (cervix 3 cm dilated):

 BP and heart rate 4 hourly

 Temperature 4 hourly
 Uterine contractions 2 hourly
 Fetal heart rate 2 hourly
 Vaginal examination 4 hourly

Active phase (cervix 4 cm dilated, fully effaced):

 Maternal condition

- BP 4 hourly
- Heart rate ½ hourly
- Temperature 4 hourly
- Urine test when urine is passed

 Fetal condition

- Fetal heart rate ½ hourly – between, during and after contractions

- Colour of the liquor 2 hourly if the membranes have ruptured
- CTG in high risk women

 Progress of labour

- Frequency and strength of uterine contractions ½ hourly

- Level of the presenting part (in fifths above the brim) 4 hourly, then 2
hourly with cervix ≥6 cm dilated
- Cervical dilatation 4 hourly, then 2 hourly with cervix ≥6 cm dilated
- Caput and moulding 4 hourly, then 2 hourly with cervix ≥6 cm dilated

 Treatment given

- All medications
- All fluids administered, by whatever route

THE PARTOGRAM: ALERT AND ACTION LINES

Record all findings of maternal and fetal condition, and of progress in labour, on
the partogram. Also record all intravenous fluids administered, and the use of
oxytocin, where indicated.
As soon as the active phase of labour is diagnosed, draw an alert line at a slope
of 1 cm/hour from the first cervical dilatation that is 4 cm dilated. Alternatively, if
 26

the partogram has a pre-drawn alert line, the first cervical dilatation noted in the
active phase of labour is placed on the alert line.

The action line is drawn 2 hours to the right of and parallel to the alert line, and
represents poor progress where ‘action’ is indicated (amniotomy or oxytocin
infusion or caesarean section). The action line may be used by midwife obstetric
units (MOUs) to guide transfer of women with poor labour progress to hospital.

ANALGESIA IN LABOUR

Analgesia should not be withheld from women in labour

 Support and companionship have been shown to reduce the need for
analgesic medication in labour
 Pethidine 1 mg/kg, (maximum dose 100 mg)
OR
Morphine 0.1 mg/kg (maximum dose 10 mg) IM 4 hourly is acceptable in both
latent and active phases of labour.
There is no need to run a CTG tracing before giving opioids.
 Metoclopramide 10 mg IM 4 hourly is given for nausea.
 Inhaled 50%/50% oxygen/nitrous oxide mixture by mask is useful in the late
first stage (cervix dilated ≥8 cm). It may cause nausea and light-headedness.
 Epidural analgesia is useful in women with excessive pain, prolonged labour,
hypertension, preterm labour and twin gestation; the anaesthetic department
is responsible for administration and monitoring of epidural anaesthesia

FETAL MONITORING

For low risk labour, listen to the fetal heart with a stethoscope or hand-held
Doppler instrument every 30 minutes, between, during and after contractions.
Cardiotocography (CTG) is used for high risk labour.

Some indications for CTG monitoring in labour

 Previous caesarean section
 Meconium stained liquor
 Maternal pyrexia, offensive liquor or suspected chorio-amnionitis
 Labour progress which has crossed the alert line
 Suspected intrauterine growth restriction
 Suspected fetal distress
 Oxytocin augmentation
 Prolonged rupture of membranes (>24 hours)
 Pre-eclampsia
 Induction of labour for post-term pregnancy
 Antepartum haemorrhage
 Multiple pregnancy
 27

Correct completion of a partogram – normal labour. This woman presented in

the active phase of labour (cervix 5 cm dilated) at 14:00 and made good progress
to full dilatation. Progress crossed neither the alert nor the action line, and head
descent was rapid from 3/5 above to 0/5 above the brim in 3 hours.
 28

THE SECOND STAGE OF LABOUR

The second stage starts when the cervix reaches full dilatation (10 cm). From the
time that full dilatation of the cervix is first noted, 1-2 hours may pass before the
woman starts to push. Time can be allowed for the head to descend onto the
pelvic floor if fetal distress and cephalopelvic disproportion are ruled out.
Continue with observations as for the first stage of labour. Encourage bearing
down only when the fetal head starts to distend the perineum and the woman has
an urge to push.

When the woman is ready to push:

 Communicate clearly to gain co-operation – be supportive and encouraging

 Put the woman in a suitable position: propped up, sitting, squatting, kneeling,
semi-Fowler’s or wedged supine. Avoid the flat supine position as the
pregnant uterus may compress the aorta and inferior vena cava
 During contractions, tell the woman to take a deep breath, put her chin on her
chest and push for as long as possible (up to 10 seconds at a time) to deliver
the baby. She should bear down towards her anus, as if to pass stool.
 Listen to the fetal heart rate between alternate contractions
 Protect the perineum when the head crowns
 Record the times of onset of the second stage, start of pushing, and delivery

EPISIOTOMY

Indications for episiotomy include:

 Thick or rigid perineum prolonging the second stage of labour

 Appearance of a very short perineal body (high risk of third-degree tear)
 Fetal distress in the second stage of labour where episiotomy may
significantly speed up delivery
 Forceps delivery (usually)
 Breech delivery (usually)

Routine episiotomy is not necessary for vacuum delivery, nor for delivery of a
preterm baby

Inject local anaesthetic (lidocaine 1% solution, maximum 20 mL) into the

perineum before cutting the episiotomy. Perform a mediolateral episiotomy –
avoid midline, lateral or bilateral episiotomy. The cut should start at the fourchette
in the midline, at an angle of 40 to 60 degrees from the midline, and be made as
the head is crowning, when the fourchette is stretched and thin.
 29

Repair of episiotomy

1. Use 1/0 to 2/0 absorbable suture; polyglycolic acid suture is recommended

2. Place a vaginal tampon high in the vagina with an artery forceps attached
3. Make sure that the anal sphincter is not disrupted
4. Insert a suture to close the apex of the episiotomy in the vaginal epithelium
5. From the apex down, close the vaginal epithelium with a continuous suture
6. Ensure correct alignment by checking the apposition of the hymen and the
vaginal-perineal junction
7. Approximate the perineal muscles and fascia with interrupted sutures
8. Close the skin with interrupted sutures or a continuous subcutaneous suture
9. Remove the vaginal tampon and record this in the notes
10. By rectal examination, check for any stitches placed in the rectum and record
this in the notes. Remove any sutures found in the rectum and repair again

THE THIRD STAGE OF LABOUR

This stage starts immediately after delivery of the infant and ends with delivery of
the placenta. The third stage should be managed actively, as follows:

 Immediately after delivery of the baby, ensure by abdominal palpation that

there is no undiagnosed second twin, even if antenatal ultrasound suggests a
singleton pregnancy
 If there is no second twin, give oxytocin 10 units IM into the thigh
 Dry and wrap the baby or give it to the mother for skin-to-skin contact
 Delay cord clamping for 1-2 minutes unless there is urgency to resuscitate
 Hold the newborn at the level of the placenta whilst awaiting cord clamping
 Await uterine contraction after about 2-3 minutes, and place the left hand on
the woman’s abdomen over the uterus. Do not rub the uterus at this stage
 When the uterus is felt to contract, pull steadily down on the umbilical cord
with the dominant hand, and push the uterus upwards with the other hand
 Deliver the placenta by continuous gentle traction on the cord
 Massage the uterus to expel clots and ensure contraction
 Examine the placenta for completeness and any abnormalities

THE FOURTH STAGE OF LABOUR

This stage is defined as the first hour after delivery of the placenta. The woman is
at risk for postpartum haemorrhage and must be observed closely.

 Check if the uterus is well contracted

 Observe continuously for excessive vaginal bleeding
 Check and record the woman’s heart rate, BP and temperature
 30

During this time, the baby can be given to the mother. Record the heart rate, BP
and vaginal bleeding again after one hour. At the end of the fourth stage, the
mother can be given something to eat and be sent to the postnatal ward.
 31

HOME DELIVERY – ‘BORN BEFORE ARRIVAL’

After home or in-transit delivery, the mother and baby require full assessment
and examination to detect any risk factors or problems. For the mother:

 Check the antenatal card carefully for risk factors and problems
 If the woman is unbooked, do RPR and Rh blood tests, and offer HIV testing
 Ask about the circumstances of the delivery
 Examine the woman for evidence of systemic illness, e.g. pneumonia, severe
blood loss, retained products of conception and perineal injury, and manage
appropriately
 Give oxytocin 10 units IM

HIGH RISK CONDITIONS FOR TRANSFER TO HOSPITAL IN LABOUR

Primigravida 35 years

Parity 5
Previous caesarean section or uterine surgery
Previous postpartum haemorrhage requiring blood transfusion
Serious medical disorder (e.g. diabetes, epilepsy, symptomatic asthma)
Heart disease
Anaemia (Hb <10 g/dL)
Hypertension or eclampsia
Multiple pregnancy
Breech presentation or transverse lie
Estimated fetal weight <2 kg; SFH <30 cm
Suspected big baby >4 kg; SFH >40 cm
Rupture of the membranes before the onset of labour
Maternal pyrexia 37.5 degrees
Vulvovaginal sores or blisters
Extensive vulvovaginal warts that may obstruct delivery
Antepartum haemorrhage
Suspected fetal distress
Thick meconium staining of the liquor
Offensive liquor
Cord prolapse
Poor progress in latent phase of labour (8 hours)
Poor progress in active phase of labour (crossing 2-hour partogram action line)
Poor progress in second stage of labour (1 hour)
Any woman who is in shock, short of breath or appears very ill
 32

ABNORMALITIES OF THE FIRST STAGE OF LABOUR

PROLONGED IN THE LATENT PHASE

The latent phase is prolonged when it exceeds 8 hours.

Management of suspected prolonged latent phase

 Exclude other causes of abdominal pain, e.g. abruptio placentae, urinary tract
infection, chorio-amnionitis
 Exclude false labour – characterised by no cervical changes and no increase
in strength, regularity or frequency of labour pains. Women in false labour
may be discharged home if there are no other obstetric problems
 If the woman is in the latent phase of labour, and after excluding fetal distress
and obvious cephalopelvic disproportion, perform ‘stretch and sweep’, rupture
the membranes and/or start an oxytocin infusion as for the active phase of
labour.

POOR PROGRESS IN THE ACTIVE PHASE

Labour is prolonged if the cervix dilates at <1 cm/hour (crosses the alert line).
Partograms illustrating poor labour progress are shown on pages 33 and 34.

 Use the rule of 4 Ps in the assessment – Patient (bladder, hydration,

psychological state, pain), Powers, Passage, Passenger
 Exclude conditions requiring immediate caesarean section:
- Cephalopelvic disproportion (big baby, short woman, increasing grade
of lambdoid & sagittal suture moulding with no descent)
- Malpresentation: breech presentation, face presentation, transverse lie
- Fetal distress, run a CTG tracing
 Ensure adequate hydration: start an intravenous infusion of Ringer-Lactate to
run at 125 mL/hour (non-cardiac, non-hypertensive women)
 Ensure that the bladder is empty; catheterize if necessary
 Give analgesia, epidural or pethidine/morphine
 Rupture the membranes if still intact
 In nulliparas, consider oxytocin infusion; use oxytocin in multiparas only if
certain that there is no cephalopelvic disproportion.

MECONIUM STAINING OF THE LIQUOR

Thin meconium staining (no solid particles) requires no specific management.

Thick meconium staining is associated with an increased risk of fetal distress:
 Monitor the fetus with a CTG if available
 When the head extends at delivery, do not attempt suction of the
nasopharynx. Continue delivery as normal
 Have a paediatric doctor in attendance for immediate resuscitation if needed
 33

Partogram – poor progress due to cephalopelvic disproportion. This woman

presented in active phase of labour. Her labour is prolonged as a result of
cephalopelvic disproportion. Note failure to progress (arrest at 5 cm cervical
dilatation) on oxytocin augmentation, with an increase in moulding score and
failure of descent of the fetal head (head remains at 4/5 palpable above the
brim).
 34

Partogram – poor progress due to inadequate contractions. This woman

presented in active phase of labour. Her labour is prolonged as a result of
inefficient uterine action. Oxytocin augmentation is followed by rapid progress
from 6 to 10 cm cervical dilatation, and descent of the fetal head from 3/5 to 1/5.
Continuous CTG monitoring was used during oxytocin augmentation.
 35

OXYTOCIN FOR AUGMENTATION OF LABOUR

1. Add 2 units oxytocin to 200 mL of Normal saline (OR 10 units oxytocin to

1000 mL of N/Saline)
2. Start infusion at a rate of 12 mL/hour – equivalent to 2 mU/minute
3. Increase by 12 mL/hour every 30 minutes until a minimum of 3 strong
contractions (>40 seconds) in 10 minutes is achieved
4. Most women will experience 3-4 strong contractions in 10 minutes at a rate of
12 mU/minute (72 mL/hour)
5. When the desired contraction frequency is reached, do not increase the
infusion rate further
6. The maximum infusion rate should not exceed 120 mL/hour (20 mU/minute)
7. Consider caesarean section if labour does not progress adequately after 4
hours of oxytocin in the active phase of labour

Precautions

 There must be no evidence of cephalopelvic disproportion

 There must be no evidence of fetal distress
 Use continuous CTG monitoring
 Use with caution in multiparas. Do not use oxytocin with parity 5 or previous
caesarean section

Recommended Oxytocin Infusion

Time Volume Oxytocin 2 IU in 200 mL 10 IU in 1000 mL

Dose
0 min 12 mL/hour 2 mU/min 12 mL/hour 12 mL/hour
30 24 4 24 24
60 36 6 36 36
90 48 8 48 48
120 60 10 60 60
150 72 12 72 72
180 84 14 84 84
210 96 16 96 96
240 108 18 108 108
270 min 120 mL/hour 20 mU/min 120 mL/hour 120 mL/hour
 36

EMERGENCIES IN LABOUR AND PROLONGED SECOND STAGE

FETAL DISTRESS

Fetal distress is suspected when any of the following signs are observed:

 Baseline fetal heart rate >160 beats per minute

 Baseline fetal heart rate <110 beats per minute
 Baseline variability persistently ≤5 beats per minute on CTG (in the absence
of sedating drugs)
 Late decelerations of the fetal heart rate
 Persistent severe or atypical variable decelerations
 Thick meconium staining of the liquor

Management of fetal distress

1. Explain the problem to the woman

2. Place the woman in a left lateral position
3. Ensure that the fetus is viable (estimated fetal weight >800-900 g) and has no
obvious lethal congenital abnormalities
4. Perform vaginal examination for cervical dilatation, and to exclude cord
prolapse or cord presentation
5. Unless hypertensive or cardiac, give a 500 mL intravenous bolus of Ringer-
Lactate
6. Stop oxytocin infusion if labour is induced or augmented
7. Give oxygen by face mask for a brief period, using equipment to achieve an
FiO2 of 80%
8. If the fetal heart rate shows no improvement:

- If vaginal delivery is imminent (cervix fully dilated), deliver immediately, by

vacuum extraction or forceps if feasible and necessary
- If vaginal delivery is not imminent, give salbutamol 250 mcg IV over 2
minutes and prepare for immediate caesarean section

9. Call the neonatology doctor to be present at birth

 37

CORD PROLAPSE

Cord prolapse is associated with preterm labour, high presenting part or

malpresentation. It should be looked for where there is sudden onset of variable
decelerations on CTG, and after performing artificial rupture of membranes.

If the fetus is alive (cord pulsating or fetal heart heard or detected on

ultrasound) and viable (estimated weight >800-900 g):

1. Call for help

2. Explain the problem to the woman
3. Perform vaginal examination:

 If the cervix is fully dilated and the woman can push the head or breech
to the pelvic floor, deliver immediately, by vacuum or forceps if
necessary

 If the cervix is not fully dilated, arrange an urgent caesarean section and
proceed as follows:

1. Replace the cord in the vagina, and handle the cord as little as possible
2. With the fingers, push the presenting part off the cord. Do not remove the
fingers from the presenting part if the cord is compressed
3. Give a 500 mL intravenous infusion bolus of Ringer-Lactate, unless
hypertensive or cardiac (no bolus, 70-100 mL/hour)
4. Give salbutamol 250 mcg IV over 2 minutes
5. Insert an indwelling urinary catheter, at least size 18 F and empty the bladder
6. Rapidly fill the bladder with 400 mL saline, then clamp the catheter
7. Place the woman in a left lateral position with buttock support, or in the knee-
elbow position if the presenting part is engaged in the pelvis and compressing
the cord
8. Make accurate notes of all that was done, with times
9. Before starting the caesarean section, make sure the baby is still alive
10. At caesarean section, bear in mind the full bladder and remove the catheter
clamp as soon as the uterus is ready for incision

If the baby is not alive or non-viable, continue labour in the safest way for the
woman, with appropriate analgesia or sedation

Cord presentation

In cord presentation, the umbilical cord can be felt behind intact membranes in
front of the presenting part. Unless the cervix is fully dilated and the head is on
the pelvic floor, this requires emergency caesarean section. If the membranes
rupture while waiting for caesarean section, immediately check for cord prolapse
and manage appropriately.
 38

SHOULDER DYSTOCIA

This occurs with large babies (usually >4 kg) when delivery of the head is not
followed by delivery of the shoulders. To anticipate shoulder dystocia, be aware
of risk factors such as an obese woman, diabetic woman, previous large baby,
prolonged labour, and SFH >40 cm. Frequently, shoulder dystocia occurs without
any identifiable risk factor.

1. Call for at least 2 assistants to help with delivery

2. Explain the problem to the woman
3. Immediately move the woman to the edge or end of the delivery bed
4. Get the woman to hyperflex her hips with the help of assistants. Her knees
should almost touch her shoulders (McRoberts’ position)
5. Apply suprapubic pressure to force the anterior shoulder under the symphysis
6. Hold the head with two hands and deliver, but do not pull on and bend the
neck, as this may cause brachial plexus injury
7. If unsuccessful, deliver the posterior arm by finding the posterior shoulder in
the vagina and sweeping the arm in front of the chest. Once the posterior
arm is delivered, proceed to deliver the anterior shoulder as above
8. If this fails, attempt to pull down the posterior arm by using a suction tube or
urinary catheter bag tube inserted behind the posterior axilla
9. Consider turning the woman to a knee-elbow position and attempting to
deliver the posterior arm as above
10. If the baby is dead, avoid traumatic manoeuvres and await spontaneous
delivery. Call for help if delivery is excessively delayed
11. After delivery, carefully inspect the perineum for damage, especially third
degree tear
12. Make clear notes about the actions taken, with times

Alternative methods in extreme cases include:

 Rotation of the baby so that the posterior shoulder becomes anterior

 Fracture of one or both clavicles
 Hyperextension of hips with legs over the edge of the bed
 Cephalic replacement using the Zavanelli manoeuvre with salbutamol
tocolysis, followed by caesarean section
 Symphysiotomy
 39

POOR PROGRESS IN THE SECOND STAGE

The labour ward midwives should call a doctor:

 If the woman has not started pushing after 1 hour of full dilatation, or
 If delivery has not occurred after 45 minutes of pushing in a nullipara, or 30
minutes of pushing in a multipara

If the woman is not bearing down after 1 hour of full dilatation:

1. Re-examine to make sure the cervix is fully dilated

2. Rupture the membranes if they are still intact
3. Exclude cephalopelvic disproportion, fetal distress or breech presentation:
these will necessitate caesarean section
4. Estimate descent of the head in fifths palpable above the brim, i.e. the portion
of head that still needs to descend into the pelvis
5. If the head is on the perineum, ask the woman to push, then assess descent
and deliver if appropriate
6. If not for immediate delivery, start oxytocin infusion
7. Continue routine monitoring of the second stage
8. Re-assess after one more hour: if not delivered, caesarean section or
assisted vaginal delivery will be required
9. With epidural analgesia, the second stage may be allowed to extend to three
hours, provided there is no evidence of disproportion or fetal distress

Failure of the head to descend despite pushing

If delivery has not occurred after 45 minutes of pushing in a nullipara, or 30

minutes in a multipara:

 Perform assisted vaginal delivery if the head is 0/5 or 1/5 palpable above the
pelvic brim, with oxytocin infusion if necessary
 Perform caesarean section if the head is 2/5 or more palpable above the
pelvic brim

INSTRUMENTAL VAGINAL DELIVERY

VACUUM EXTRACTION

Vacuum extraction may be performed by advanced midwives and doctors

Indications for vacuum extraction

 Maternal cardiac or respiratory disease, or BP≥160/110 mmHg

 Fetal distress in the second stage of labour
 Prolonged second stage with inadequate pushing or maternal exhaustion
 40

Conditions for safe vacuum extraction

 Vertex presentation, does not have to be occipito-anterior

 Estimated fetal weight 2 kg
 Head not more than 1/5 palpable above the pelvic brim
 Cervix fully dilated
 Membranes ruptured
 Bladder empty – insert a urinary catheter, leave the bulb deflated
 Strong uterine contractions (>40 seconds) – use oxytocin if necessary

Equipment and techniques vary. Disposable Kiwi hard and soft cups, soft Silc
cups and Bird metal cups (anterior 50 and 60 mm, and posterior 50 mm) are
available. Hard cups give better traction force, and for these at least 3-4 minutes
should be given for the cup to become securely attached to the head vacuum. A
negative suction pressure of 0.7 to 0.8 Bar is needed for effective traction.

Important practical points and precautions

 Check and test the equipment thoroughly before using it

 Check the fetal heart rate just before starting the procedure
 Apply traction only during contractions, with maternal pushing
 Traction must be in a direction perpendicular to the vacuum cup
 During traction with the dominant hand, keep fingers of the other hand on the
vacuum cup and head, to feel for decent and detect incipient cup detachment
 Failed vacuum extraction is an indication for caesarean section:
- There should be noticeable descent with each pull
- The vacuum cup must not be applied for more than 30 minutes
- No more than 2 cup detachments are allowed
- No more than 3 pulls (one pull = one contraction) are allowed
 Write up the procedure fully: operator, indication, clinical findings included
level of head in fifths, time taken, cup type and size, number of pulls, number
of detachments, and baby’s condition at birth

FORCEPS DELIVERY

Forceps delivery is associated with greater maternal trauma and pain than
vacuum extraction, but is useful for face presentation, unconscious women and
women with cardiac disease. Wrigley or Anderson forceps are used. In addition
to those that apply to vacuum extraction, the following precautions must be
observed:

 Forceps delivery must be done or supervised by an experienced person

 Fetal head position must be direct occipito-anterior
 The head must be 0/5 palpable above the brim (outlet forceps)
 Use pudendal block for analgesia
 41

PUDENDAL BLOCK

Transvaginal pudendal block can be employed for any vaginal delivery where
analgesia is needed, but is especially useful for forceps delivery.

1. Use a guarded needle with an introducer if available

2. Use lidocaine 1% solution
3. For the right pudendal nerve, identify the right ischial spine with the right
index and middle fingers
4. Pass the needle next to the fingers and inject about 2 mL of lidocaine into the
sacrospinous ligament
5. Inject a further 2 mL just beyond the sacrospinous ligament
6. Withdraw the needle out of the ligament and inject about 5 mL just lateral and
above the ischial spine
7. Repeat the procedure on the left side
8. Inject any remaining lidocaine along the track of a proposed episiotomy
9. Remember to withdraw the syringe plunger before every injection to prevent
accidental intravascular injection

CAESAREAN SECTION

Surgical techniques vary according to the circumstances, and experience of the

operator. The Joel-Cohen transverse abdominal approach is preferred

NOTES ON CAESAREAN SECTION

 Give sodium citrate 30 mL orally 30 minutes before the expected start of the
operation, not necessarily at the time of booking
 Give metoclopramide 10 mg IM 30 minutes before the start of the operation
 Just before starting the operation, ensure that:
- Tubal ligation has been considered with the necessary consent signed if
that is the woman’s choice
- The fetal heart can still be heard
- The indication for operation is still valid, and known to the woman
- The fetal presentation and position are known
 Give a broad spectrum antibiotic as a single dose, eg Cefazolin 1 g IV, one
hour before the procedure, irrespective of whether the operation is elective or
emergency
 Consider a vertical skin incision with previous vertical incision, or risk of intra-
operative haemorrhage (antepartum haemorrhage, severe pre-eclampsia),
difficult delivery (transverse lie, prolonged second stage), or postoperative
infection (prolonged labour or rupture of membranes, offensive liquor)
 42

 Consider a vertical uterine incision (classical, but usually down into the lower
segment) for extensive lower segment adhesions, lower uterine leiomyomas,
transverse lie, poorly formed lower segment (especially with preterm breech
presentation) and cervical cancer (high vertical incision)
 Ensure that oxytocin 2.5 units is given IV slowly after delivery of the baby, to
be repeated after 3 minutes if the uterus does not contract adequately
 Take special care in caesarean delivery where the head is deeply engaged.
Ask for help in pushing the baby up from below, or consider a ‘reverse
breech’ method. Get senior help if inexperienced with such situations
 For persistent excessive bleeding, inform the anaesthetist and get senior
help. Identify and control bleeding points, also manage as for persistent
postpartum haemorrhage including uterotonics and tranexamic acid
 Immediate postoperative IV fluids are usually Ringer-Lactate 1 L with 40 units
oxytocin over 8 hours (5 units/hour), followed by 1 L of Plasmalyte over 8
hours (125 mL/hour)
 Start postoperative mobilisation and feeding as soon as the woman feels
strong enough and hungry
 Prescribe postoperative intravenous broad-spectrum antibiotics (e.g. Co-
amoxyclav 1.2 g IV 8 hourly) for women where there has been offensive
liquor (chorio-amnionitis) during labour
 Prescribe postoperative analgesia: Morphine 0.1 mg/kg IM 6 hourly with
metoclopramide 10 mg IM 6 hourly for 24 hours.
 Add ibuprofen 400 mg 8 hourly orally and paracetamol 1 g 6 hourly orally.
 Avoid ibuprofen in patients with renal dysfunction, severe pre-eclampsia,
asthma, or a history of peptic ulcers. Give tramadol 100 mg orally 6 hourly
 Consider thromboembolism prophylaxis for women who may be at risk
(enoxaparin 40 mg daily SC while in hospital from 12 hours post-op and not
bleeding) – e.g. women who are obese (>100 kg; BMI >30 kg/m2), or have co-
morbidity such as hypertension and other medical conditions
 Discharge the woman from hospital on the third postoperative day if she is
feeling well, is apyrexial, and has a heart rate <100/min. Discharge on the
second day is permissible if there are no specific risks of problems. Advise on
contraception, and refer to local clinic for follow-up and removal of sutures.

PRE-OPERATIVE TESTING BEFORE CAESAREAN SECTION

Recommended testing for various situations:

 Healthy women with no medical problems: Hb, Platelets, Creatinine

 Mild pre-eclampsia and gestational hypertension: FBC, U&E
 Severe pre-eclampsia: FBC, U&E, AST, INR if platelet count <100109/L
 Abruptio placentae: U&E, FBC, INR
 Cardiac disease: electrocardiogram (ECG), echo, FBC, INR on warfarin
 Women with AIDS, or systemic infections: U&E, FBC
 43

Further points

 Spinal block is acceptable if platelet count 75109/L provided there is no

other evidence of coagulopathy
 For an operative procedure, platelet count should be 50109/L
 It may be inappropriate to wait for results in an emergency
 Encourage good communication between obstetrician and anaesthetist
 Request detailed pre-anaesthetic assessment for high risk patients

REQUESTS BY WOMEN FOR CAESAREAN SECTION

Caesarean section is associated with an increased risk of maternal infection,

haemorrhage, thromboembolism, adhesions, and placenta accreta or uterine
rupture in a subsequent pregnancy. Women who ask for caesarean section and
have a relative indication, e.g. poor obstetric history or previous caesarean
section, may be scheduled for elective caesarean section. It is policy in public
hospitals not to perform caesarean section for the sole reason that a woman is
HIV infected, or upon her request.

Inform women who request caesarean section with no indication about the
possible risks and benefits of the procedure. In public hospitals, performing
caesarean section without a clinical indication is unacceptable practice.

WOMEN WHO REFUSE CAESAREAN SECTION

Some women refuse caesarean section and put the lives of themselves and their
babies at risk. No person can be physically forced to undergo surgery. The
following stepwise procedure may help such a patient to agree to the operation:

1. Listen carefully to the reasons for refusal and take these into account
2. Give a full explanation in the language best understood by the woman
3. Call the most senior doctor and nurse available to explain the situation
4. Call the closest relatives to explain the need for surgery
5. Call the hospital clinical director or ethics committee to ask for further advice
 44

IMMEDIATE CARE OF THE NEWBORN

NEONATAL RESUSCITATION

General Principles
Every birth should be attended by at least one person whose sole responsibility
is management of the newborn. All staff who conduct deliveries should be able to
resuscitate and provide immediate care to newborn infants.

Babies that may require resuscitation

Always ensure that a skilled doctor or nurse is available at birth for the following:

 Meconium-stained liquor or any other evidence of fetal distress

 Prematurity (<36 weeks), Postmaturity (>42 weeks), anticipated small baby
(<2 kg) or large baby (>4 kg).
 Multiple pregnancy, major congenital abnormalities or hydrops fetalis
 Cord prolapse
 Abruptio placentae
 Prolonged or difficult labour
 Malpresentation

Apgar scores must be assigned at 1 and 5 minutes. In addition, even before 1

minute, ask yourself the following questions:

 Is the amniotic fluid clear or meconium-stained?

 Is the baby breathing or crying?
 Is there good muscle tone?
 Is the colour pink?
 Was the baby born at term?

If the answer is YES to all these questions, provide routine care:

1. Provide warmth
2. Clear the airway only if there are secretions, wiping the mouth and nose with
gauze, cotton wool or clean linen. Do not suction
3. Dry the baby and remove the wet linen
4. Maintain warmth by putting the infant directly on the mother’s chest (skin to
skin) and covering with dry linen
5. Do not separate these babies from their mothers
6. Start feeds within an hour after birth, breastfeed unless contraindicated.
 45

If the answer is NO to any of these questions, evaluate and resuscitate:

 Provide warmth
 Place the infant on a flat surface facing up with the head supported in a
neutral position (not flexed, not hyperextended)
 Suction the mouth and nose only when necessary – when there are
secretions that may obstruct the airway
 Dry the baby and remove the wet linen
 Provide gentle tactile stimulation (slapping the feet or gently rubbing the back)
for 2-3 seconds if the infant is not crying.
 Determine the baby’s colour, respiratory effort and heart rate. Listen to the
heart rate with a stethoscope over the apex for 6 seconds and multiply by 10

If the infant is not breathing or breathing irregularly or heart rate is <100/

minute, call for help and start resuscitation:

A. Airway: Maintain the head in a neutral position, clearing secretions by gentle

suction.

B. Breathing: Start bag mask ventilation (BMV) using room air at 30-40
breaths/minute. Ensure slight chest rise with each breath. If the chest does
not move, check the seal of the mask on the baby’s face, and check for
flexion or overextension of the neck. Reassess colour, respiratory effort and
heart rate after 30 seconds. Most infants will respond to BMV. Stop bagging
only if the infant is breathing regularly, and only give oxygen. If not breathing
and heart rate is >60/minute continue ventilating with up to 100% oxygen and
reassess every 30 seconds until the infant starts breathing.

C. Circulation: Intubate and start chest compressions if the heart rate is

<60/minute despite BMV with oxygen. Perform chest compressions using
index and middle fingers placed on the lower third of the sternum to depress
the chest to about a third of its anterior-posterior diameter. An alternative
method can be employed by encircling the infant’s chest with both hands and
using both thumbs to compress the chest. Give compressions at a ratio of 3:1
(three chest compressions to one ventilation). Reassess after 30 seconds and
if the heart rate is still <60/minute give adrenalin 1:10 000 at 0.1-0.3 mL/kg
intravenously. If adrenalin is instilled into the endotracheal tube it is given
undiluted at a strength of 1:1000 at 0.1-0.3 mL/kg. This may be repeated
every 3-5 minutes. Give naloxone only after establishing good ventilation and
only if the mother received narcotics in the last 4 hours of labour.

Babies who require prolonged BMV or more extensive resuscitation are at high
risk for developing subsequent complications. These infants must be admitted for
ongoing monitoring and support. Keep them warm, monitor temperature,
respiration, heart rate, blood pressure, glucose and urine output.
 46

NB
For all newborns with birth weight ≥2.5 kg who required immediate resuscitation
at birth, or with 5-minute Apgar <7, send the placenta in 10% formalin for
histopathological examination.

IMMEDIATE CARE OF THE WELL NEWBORN

 Wear protective gloves when handling a newborn who has not been bathed
 Maintain the baby’s temperature by warming the environment, drying the
infant immediately after birth, and encouraging skin-to-skin contact with the
mother
 Assign an Apgar score at 1 and 5 minutes
 Do physical examination to look for congenital abnormalities
 Take measurements (weight, length and head circumference)
 Skin care – use a cloth or cotton wool with tap water to remove blood and
meconium. Do not remove the vernix caseosa
 Eye care – apply chloramphenicol or erythromycin ointment within an hour
after birth
 Give vitamin K 1 mg IM within an hour after birth
 Start feeds within an hour after birth. Breastfeed unless contraindicated

The Apgar score. Scores for each are added, to a total out of 10.

Sign
Score
0 1 2

Colour Blue or pale Pink body, blue All pink

extremities
Heart rate Absent <100 beats per minute >100 beats per
minute
Respiratory Absent Gasping or irregular Regular or crying
Effort
Muscle tone Limp or Some flexion of Active movement
floppy extremities
Response to No response Grimace Cry or cough or
stimulation sneeze
 47

 Provide warmth
 Position, suction as necessary
 Dry and remove wet linen
 Stimulate if not crying or breathing

Supportive care if
Evaluate breathing, heart colour pink, Heart
rate and colour rate>100/min and
breathing

If breathing is irregular or heart rate

<100/min, start bag mask ventilation
(BMV) with room air. If heart rate <60/min,
start chest compressions and BMV with
oxygen and continue for 30 seconds

Ongoing care and

Evaluate breathing, heart monitoring if colour pink,
rate and colour Heart rate>100/min and
breathing

If heart rate still <100/min after BMV,

continue BMV with oxygen. If heart rate
<60/min, continue or start chest
compressions (consider intubation) and
continue for 30 seconds.

Evaluate breathing, heart Ongoing care and

rate and colour monitoring if colour pink,
heart rate >100/min and
breathing

If HR remains <60/min, continue BMV, chest

compressions, then intubate and give
adrenalin intravenously or through the
endotracheal tube

NEONATAL RESUSCITATION
 48

ABNORMALITIES OF THE THIRD AND FOURTH STAGES OF LABOUR

RETAINED PLACENTA

The placenta is retained when it is not delivered from the uterus within 30
minutes of delivery of the baby. At times, the placenta is not truly retained, and it
may be removed by simply lifting it out of the vagina, or manually helping it out of
the cervix.

Management of retained placenta

1. Ensure that the bladder is empty by passing a urinary catheter

2. Start an infusion with oxytocin 20 units in 1L Ringer-Lactate at 250 mL/hour
3. Observe the woman constantly for vaginal bleeding or placental delivery
4. If there is excessive vaginal bleeding, or if the placenta has not been
delivered after one hour of oxytocin infusion, arrange for manual removal in
theatre under general anaesthesia
5. Take blood for Hb and crossmatch, and order 2 units of packed cells on
standby
6. Just before anaesthesia is given, check if the placenta has passed into the
cervical canal or vagina
7. For manual removal, try to remove the whole placenta with the hands. Use
the ulnar surface of the palm to create a cleavage plane. If instruments are
required, use the largest available forceps and curettes, to prevent uterine
perforation
8. Call for senior help if bleeding persists or if placenta accreta is suspected
9. Give ampicillin 1 g IV followed by amoxycillin 500 mg 3 times daily orally and
metronidazole 400 mg 3 times daily orally for 5 days

ACUTE INVERSION OF THE UTERUS

This emergency requires immediate action to prevent haemorrhage, shock and

maternal death. Acute uterine inversion may be caused by inappropriate cord
traction on a fundal placenta in a flaccid uterus, without providing the necessary
upward counter-pressure on the uterus. At times it occurs spontaneously. Often,
clinical shock is greater than expected for the amount of blood loss.

1. Immediately treat shock with Ringer-Lactate given through 1 or 2 lines using

large bore (16G) IV cannulas
2. Explain the problem to the woman
3. Order blood for transfusion if there is haemorrhage
4. Give pethidine 50-100 mg IV if systolic BP ≥90 mmHg
5. Do not remove the placenta if it is still attached to the uterus
6. Give salbutamol 250 mcg IV to relax the uterus
 49

7. Place the flat hand against the inverted surface of the uterus and push the
uterus (with placenta if attached) as high up into the vagina as possible and
hold that position for several minutes. Reduction should occur with sustained
upward pressure (Johnson method)
8. If reduction is not achieved, fill the vagina with 500-1000 mL of saline, using a
vacuum cup or other device to provide an external seal (O’Sullivan method)
9. Once reduction has been achieved, give syntometrine 1 amp IM and oxytocin
20 units in 1 L Ringer-Lactate. Do not remove the hand from the uterine cavity
until a firm uterine contraction is felt
10. Carefully deliver the placenta when signs of separation are observed
11. If the placenta is not expelled spontaneously from the uterus, manual removal
needs to be done in theatre
12. Observe the woman closely for haemorrhage or re-inversion
13. Failed reduction requires laparotomy. Using Allis clamps, pull on the round
ligaments where they enter the uterine constriction ring , with an assistant
pushing the inverted uterus up from below (Huntingdon method)
14. A tight constriction ring may prevent reduction. At laparotomy, the ring can be
opened by a low vertical posterior incision in the uterus (Haultain method).
Then proceed with the Huntingdon method

REPAIR OF A THIRD DEGREE TEAR

In a third degree tear, the anal sphincter is disrupted, and there may be injury to
the rectal mucosa

1. Repair should be performed by a doctor in theatre, or in labour ward if an

epidural anaesthetic is functional
2. Use polydioxanone & polyglycolic acid suture
3. Repair the rectal mucosa first with 3/0 suture, continuous or interrupted
4. Follow this by repairing the rectal muscularis layer with 3/0 suture, continuous
or interrupted. Include the internal anal sphincter in this suture
5. Identify the disrupted ends of the external anal sphincter on each side just
above the anal verge and extract and hold them with Allis clamps
6. Repair the external sphincter with 4 simple 2/0 sutures, either as an end-to-
end or as an overlapping anastomosis
7. Complete the repair as for episiotomy
8. Give antibiotic prophylaxis – ampicillin 1 g IV 6 hourly for 24 hours followed by
amoxycillin 500 mg orally 8 hourly, with metronidazole 400 mg 8 hourly, for a
total of 5 days
9. Give oral analgesia, e.g. paracetamol 1 g orally 6 hourly or ibuprofen 400 mg
orally 8 hourly for 3-4 days
10. Prescribe stool softeners, e.g. ispaghula or bran, or lactulose 10 mL 12 hourly
orally for 5 days. Advise on a high fibre diet
11. Advise on pelvic floor exercises and ask the woman to report any anal
sphincter incontinence to her clinic or doctor
 50

PRIMARY POSTPARTUM HAEMORRHAGE

Primary postpartum haemorrhage (PPH) is defined as blood loss >500 mL in the

first 24 hours after vaginal delivery, or 1000 mL after a caesarean section. A
more useful definition may be a clinically excessive blood loss after delivery.
Atonic uterus is by far the most common cause of PPH after vaginal delivery.

Causes of postpartum haemorrhage

1. Atonic uterus:
 Primary uterine atony (idiopathic)
 Retained placenta or products of conception
 Multiple pregnancy
 Multifibroid uterus
 Prolonged labour and labour augmentation
 Prolonged second stage of labour
 Abruptio placentae
 Placenta praevia (lower segment atonic)

2. Trauma:
 Ruptured uterus
 Cervical laceration
 Vaginal and perineal lacerations
 Uterine trauma at caesarean section

3. Coagulation failure (usually in synergy with the above causes)

 Abruptio placentae
 Severe pre-eclampsia
 Severe systemic or uterine sepsis
 Massive haemorrhage
 Maternal clotting disorders, e.g. von Willebrand’s disease
 Long-standing intrauterine fetal death
 Amniotic fluid embolism
 Incompatible blood transfusion.

4. Inverted uterus

Prevention of atonic uterus

Identify women with risk factors, such as multiple pregnancy, antepartum

haemorrhage, polyhydramnios, prolonged labour, history of previous postpartum
haemorrhage, vaginal birth after caesarean section, and parity ≥5 after delivery.
For these women, give oxytocin 20 units in 1L Ringer-Lactate at 125 mL/hour
after delivery of the placenta in addition to routine third stage management that
includes oxytocin 10 units IM.
 51

Management of PPH after vaginal delivery

1. Call for help and rub up the uterus to expel clots and induce contraction
2. Start a rapid infusion with 1 L Ringer-Lactate solution in one arm
3. In the other arm start oxytocin 20 units in 1 L Ringer-Lactate at 250 mL/hour
4. Ensure that the whole placenta has been delivered
5. Insert an indwelling urinary catheter

6. Look for the cause of bleeding by examining the woman’s abdomen:

 A large soft uterus is atonic: add ergometrine 0.5 mg IM (if not contraindicated
by cardiac disease and hypertension) and massage the uterus continuously; if
clots are retained in the uterus, remove them manually
 The woman may help by continuing massage of her own uterus
 A well contracted uterus with bright red fresh bleeding indicates that
haemorrhage is caused by lacerations, including possibly uterine rupture. The
lacerations need to be repaired following examination of the entire birth canal,
in the lithotomy position, in theatre under anaesthesia if necessary
 If the uterus cannot be felt through the abdomen, uterine inversion may be the
cause of haemorrhage, and can be confirmed by performing a vaginal
examination. This needs immediate reduction

7. If haemorrhage from an atonic uterus cannot be controlled:

 Continuously massage the uterus

 Continue with oxytocin infusion, and consider a repeat dose of ergometrine
 Order at least two units of packed cells urgently
 If misoprostol is to be used, give 400-600 mcg sublingually or rectally as a
single dose
 Inject prostaglandin F2-alpha 1 mg into the myometrium: dilute 5 mg in 20 mL
water and inject 2-4 mL (0.5-1 mg) through the skin into the uterine fundal
myometrium; contraindications include asthma and cardiovascular disease
 Give tranexamic acid 1 g IV over 10 minutes (also useful with lacerations)
 Insert a condom balloon or Bakri balloon into the uterus and inflate by gravity
or manually to 400 mL with saline, then pack the vagina to prevent balloon
expulsion, and observe for uterine relaxation or further bleeding. Record the
volume of fluid in the balloon. If effective, the balloon may be half-deflated
after 12 hours and removed after 24 hours.
 With further bleeding, arrange for urgent examination in theatre with manual
exploration of the uterus for rupture and retained products, and possible
laparotomy with B-Lynch brace suture, systematic devascularization (uterine
and ovarian arteries), hysterectomy or internal iliac artery ligation
 If unable to do hysterectomy and with persistent bleeding from the uterus, tie
a Foley catheter around the lower segment while awaiting help. This can also
be done at caesarean section where bleeding is uncontrollable
 52

 As a last resort, apply firm and sustained pressure to the aorta above the
level of the umbilicus and call for senior help while replacing blood loss

Inserting a B-Lynch brace suture

1. This may be done for PPH after normal delivery or after caesarean section
2. Put the woman in a modified Lloyd Davies position (thighs spread but not
flexed much), to allow surgery while observing for vaginal bleeding
3. Do a laparotomy and exteriorize the uterus
4. Open the lower segment (if not already open) with a transverse incision
5. Explore the inside of the uterus for bleeding points, and place figure-of-8
sutures over any single large bleeding points
6. Compress the uterus with the hands. If this stops the bleeding, a B-Lynch
brace suture is likely to be successful
7. Use a single 1 metre length of thick absorbable suture material (chromic 1
or 2), with a large needle
8. Ensure that the assistant compresses the uterus well while the suture is
tightened and tied
Hayman sutures or multiple square sutures, where the uterus does not need to
be opened, may be attempted as alternatives to a B-Lynch suture.

Anterior view: the stitch is inserted

below the right angle of the uterine
incision

1
2
Posterior view: the right and left
braces pass over the fundus and are
joined by the suture passing across
the lower segment through the
posterior uterine wall, at the level of
the uterosacral ligaments

Suture completed and uterus compressed.

The stitch emerges below the left angle of
3 the uterine incision with the knot in the
midline below and anterior to the incision
The B-Lynch brace suture
From: www.gyncph.dk/procedur/obstet/blch.htm
 53

Postpartum haemorrhage

 Rub up the uterus

 Call for assistance
 Two IV lines
 Oxytocin infusion 20 units in
1 L Ringer-Lactate
 Ensure placenta is complete
 Insert a urinary catheter
 Restore and maintain blood
pressure with IV fluids/blood

Abdominal examination

Uterus large Uterus well Uterus not felt

and soft contracted

Atonic uterus Lacerations Inverted uterus

 Give ergometrine Find source of Reduce immediately

0.5 mg IM, repeat bleeding: uterus,
once if needed cervix, vagina,
 Continuous perineum
massage
 Evacuate clots Repair lacerations, or
 Misoprostol 400-600 do laparotomy for
mcg sublingual ruptured uterus
 PG F2 alpha 1 mg


intramyometrial
Tranexamic acid 1g
MANAGEMENT OF
IV over 10 minutes POSTPARTUM
 Condom balloon
 Laparotomy: HAEMORRHAGE
B-Lynch or
hysterectomy
 54

CARDIOPULMONARY RESUSCITATION (CPR) IN PREGNANCY

CPR in cardiac arrest is the same for pregnant and non-pregnant patients. Only 3
evidence-based interventions are proven to be effective in cardiac arrest: 1) good
chest compressions; 2) early defibrillation; and 3) treating the cause of the arrest.
The pregnant uterus interferes with venous return and needs to be displaced to
the side by 15 to 30 degrees. This is accomplished by manual shifting and
position maintenance by an assistant. Placing a wedge to perform a lateral tilt
interferes with the performance of chest compressions.
For women in the third trimester of pregnancy, perimortem caesarean section is
performed primarily to improve maternal outcome and not to save the baby, and
must be performed within 5 minutes of the cardiac arrest – in the absence of a
maternal pulse – in order to be effective.
MANAGEMENT OF CARDIORESPIRATORY ARREST
1.”Hello Mrs Tilt”
2. Call for help and for a defibrillator. A caesarean section pack may be needed.
3. The uterus must be displaced to the left side manually by an assistant.
4. Check for a carotid pulse.
- If absent, begin CPR starting with chest compressions, using the principle
of CAB (Chest compressions, Airway, Breathing).
- Perform chest compressions at a rate of at least 100/minute.
- Push hard (at least 5 cm) and push fast. Allow full recoil of the chest.
- Give 2 breaths (1 second each) for every 30 compressions
- Repeat for 5 cycles or 2 minutes before checking for a pulse. Persons
performing the chest compressions must change every 5 cycles or 2
minutes.
5. When the defibrillator arrives, immediately perform ‘quick-look paddles’ ECG
for ventricular fibrillation (VF) or ventricular tachycardia (VT). If these shockable
rhythms are present, defibrillate. Shock with 360 J (monophasic) or 200 J
(biphasic). For a non-shockable rhythm (asystole or pulseless electric activity),
continue CPR.
6. After the first shock, give adrenaline 1 mg with a flush and repeat every 3-5
minutes, IV or intraosseous (IO). After the 2nd shock, give amiodarone 300 mg IV
with a flush if the rhythm is VF or pulseless VT. After the 4th shock, give
amiodarone 150 mg IV with a flush.
 55

7. Intubate only when skill and all equipment are available, with a minimum of
interruption to chest compressions. Consider using a laryngeal mask airway.

8. If cardiac output is not restored in 4 minutes, with a uterus of 28 weeks,

perform caesarean section at the site of resuscitation. Continue CPR during the
operation. If CPR is successful, the operation may be completed in theatre.
9. Treat the cause of asystole or pulseless electric activity

5H’s
Hypoxia
Hypovolaemia
Hyper/Hypokalaemia
H+-acidosis
Hypothermia

5T’s
Thromboembolism
Thrombosis (myocardial infarction)
Toxins or medications
Tension pneumothorax
Tamponade

How long to continue CPR

- Are there any reversible causes? Yes, continue
- Is the patient cold? Yes, warm patient and continue
- Did the patient use any drugs?
- Otherwise stop CPR after 20 minutes if no response
 56

HELLO Mrs Tilt

CALL:
For help
For a defibrillator
For a CS pack if uterus ≥28 weeks
Place back board behind patient

START CPR
Manually displace the uterus to the left
AIRWAY
Apply chest compressions at 100/min
Attempts at intubation
Give 2 breaths for every 30 compressions
may waste time and
Check carotid pulse every 2 min
interfere with chest
compressions. Use any
effective airway or mask,
including laryngeal mask
airway.
Only intubate once skills
ASSESS RHYTHM
and all equipment are
SHOCKABLE
available, with minimal
Use quick-look paddles from defibrillator
interruption to chest
compressions
Yes
No
Ventricular fibrillation
Asystole or PEA
/ V tachycardia

Shock
CPR for 2 min
CPR for 2 min Adrenaline 1mg every
Adrenaline 1mg every 3-5min
3-5min

Check rhythm shockable?

Check rhythm shockable?
YES

NO
YES
CAESAREAN SECTION CPR for 2 min
Perform CS if no cardiac output after Adrenaline 1mg every 3-
Shock
4 min of CPR 5min
Continue CPR during CS Treat reversible causes
CPR for 2 min
Amiodarone 300mg
Treat reversible
causes
 57

THE UNCONSCIOUS OBSTETRIC PATIENT

CAUSES

 Eclampsia
 Cerebrovascular accident
 Subarachnoid haemorrhage, including from a ruptured berry aneurysm
 Status epilepticus
 Amniotic fluid embolism
 Metabolic problems, e.g. hyper/hypoglycaemia, electrolyte abnormalities
 Infections – meningitis, malaria, or severe sepsis
 Hypoxia resulting from cardiorespiratory problems
 Head injury
 Drugs and poisons

Management of the unconscious obstetric patient

1. Hello Mrs Tilt

2. Call for help
3. Evaluate using the principles of CAB (circulation, airway, breathing) and
correct these, by CPR if necessary. Consider intubation
4. Assess Glasgow Coma Scale (GCS) or AVPU (alert, voice, pain, unre-
sponsive), consider intubation if coma scale ≤8 or responsive only to pain
5. Turn the woman on her left side
6. Measure BP, heart rate, respiratory rate and temperature
7. Attach a pulse oximeter
8. Take history from persons accompanying the patient and find the antenatal
record and notes of previous hospital admissions if possible
9. Do a complete physical examination, including neurological assessment and
vaginal examination
10. Evaluate systems:
- Big 5: Cerebral, Cardiac, Respiratory, Renal, Liver/gastrointestinal
Forgotten 4: Haematological, Immune, Endocrine, Musculoskeletal
Core 1: Genital system
11. Insert an intravenous line with Ringer-Lactate
12. Insert a urinary catheter
13. Do fingerprick blood glucose, U&E, FBC and ABG, and other tests if needed,
e.g. malaria smear, malaria antigen, toxicology screen, depending on
possible cause
14. Evaluate fetal condition with ultrasound and/or NST
15. Transfer to a high care area
16. Investigate and treat according to the differential diagnosis
17. Consult with appropriate colleagues, e.g. neurology, internal medicine
18. Decide on further obstetric management
 58

THE NORMAL PUERPERIUM

The puerperium lasts from delivery of the placenta up to 6 weeks after delivery. It
is characterized by a physiological return to the non-pregnant state. Mood swings
and ‘blues’ are common.

Uterine involution starts soon after delivery, with the uterus usually not palpable
above the pelvic brim 2 weeks after delivery. On vaginal examination, the cervix
will admit at least one examining finger up to about one week after delivery.

The postnatal vaginal discharge (lochia) is termed:

 Lochia rubra (blood-stained) from 1-3 days after delivery

 Lochia serosa (serous brown-yellow fluid) from 3-10 days
 Lochia alba (yellow-white discharge) from 10 to about 28 days

DISCHARGE FROM HOSPITAL AFTER NORMAL BIRTH

Discharge from hospital is permissible 6 hours after vaginal birth provided that:

 There are no surgical, medical or obstetric problems that require attention

 The woman looks and feels well
 There is no evidence of anaemia
 The heart rate (<100/min), temperature and BP are all normal
 There is no uterine tenderness
 There is no active vaginal bleeding
 There are no serious urinary symptoms (incontinence, retention)
 There is no excessive pain in the abdomen or perineum
 Breastfeeding, or formula feeding, has been explained and demonstrated
 The HIV, Rhesus blood group and RPR results are known
 Plans for contraception have been discussed

All findings should be recorded and the woman advised to attend her nearest
clinic 3-6 days after delivery for midwives’ assessment, and for examination of
the baby. Write a short discharge summary for the woman to take to the clinic.

SECONDARY POSTPARTUM HAEMORRHAGE

This is passage of fresh blood or clots from the vagina >24 hours after delivery.
The common causes are placental site subinvolution, endometritis, retained
products of conception and wound breakdown.
 59

Management of secondary postpartum haemorrhage

 Resuscitate the woman if she is shocked or has bled excessively, as for

primary postpartum haemorrhage
 Give oxytocin and ergometrine as for primary PPH
 Find out if the placenta and membranes were complete after delivery
 Carefully examine the vulva and vagina for a source of bleeding
 If the cervix is open, attempt to feel inside the uterus for retained products
 If the cervix is open in the first week after delivery, this is normal and not
necessarily a sign of retained products
 Do a transabdominal ultrasound scan where there is uncertainty about
retained products, to confirm or exclude retained placental tissue
 Specific treatment will be directed at the cause: antibiotics for endometritis,
repair of wounds, or evacuation of retained products

PUERPERAL SEPSIS

This is infection of the upper genital tract after delivery. It may involve the
endometrium, myometrium, pelvic peritoneum or the entire peritoneal cavity.

Risk factors for puerperal infection

 Caesarean section
 Prolonged labour or rupture of membranes
 Frequent vaginal examinations in labour
 Traumatic delivery
 Anaemia
 Poor immunity, such as HIV infection, diabetes and chronic steroid use
 Extensive vulval warts
 Retained placenta
 Low socioeconomic status

Mild puerperal sepsis

Clinical features include mild uterine tenderness without signs of peritonitis, a
heart rate <100/minute, temperature <37.5 degrees, and offensive lochia.

Management

 Give amoxycillin 500 mg 8 hourly orally and metronidazole 400 mg 8 hourly

orally
 If allergic to penicillin, give clindamycin 450 mg 8 hourly orally and
ciprofloxacin 500 mg 12 hourly
 Encourage adequate intake of oral fluids
 If there is evidence of retained products, admit for evacuation of the uterus
 Follow up for reassessment after 24-48 hours
 60

SEVERE PUERPERAL SEPSIS

This is postpartum infection of the genital tract, with a temperature 38 degrees,
tachycardia 100/min, the presence (not always) of offensive lochia and uterine
or abdominal tenderness. Always admit to hospital. Consider other diagnoses or
co-infections, e.g. malaria, TB, pneumonia, endocarditis, meningitis.

History

 Take a careful history of pain, discharge, bleeding and associated problems

 Consider risk factors as for mild puerperal sepsis
 Also ask about bowel, urinary tract and respiratory symptoms
 Include relevant medical history – HIV, diabetes, hypertension, travel, etc.

Examination

 Be thorough and systematic

 Note temperature, colour, heart rate, BP, and respiratory rate
 Note level of consciousness
 Examine heart and lungs, and breasts for mastitis or abscess
 Examine abdomen for distension, tenderness, rigidity, masses and bowel
sounds. Carefully inspect and palpate caesarean section wound (below)
 On vaginal examination, note state of the cervix (open, excitation tenderness,
palpable products of conception) and feel for abscesses or haematomas, and
for fluid collections in front of the cervix or in the pouch of Douglas
 Note offensiveness of the lochia
 Do speculum examination and inspect the cervix for discolouration

Special investigations

 Do ultrasound scan of the whole abdomen, looking for free fluid collections,
cysts, masses, hydronephrosis, size of uterus and retained products
 Aspirate any free fluid and note if pus, blood, serous or serosanguinous fluid
 Send aspirated fluid for MCS, and also order TB investigations (AFB, culture,
GeneXpert) on serous/serosanginous fluid
 Take blood FBC, U&E, INR, LFT, blood culture, and ABG

Multisystem evaluation

Based on the above clinical assessment and special investigations, evaluate

systems: big 5 (cerebral, cardiac, respiratory, renal and liver/gastrointestinal),
forgotten 4 (haematological, immune, endocrine, musculoskeletal) and core 1
(genital tract, breasts), and consider care for each involved organ system.
 61

Management

 With evidence of septic shock (tachycardia, systolic BP <90 mmHg), start a

rapid intravenous infusion of Ringer-Lactate 1-2 L (20 mL/kg), and closely
observe BP, heart rate and respiratory rate. Call for senior help if BP does not
respond to these measures. Manage in a high care area
 Insert a urinary catheter
 Aim for systolic BP ≥100 mmHg, or mean arterial BP ≥65 mmHg, SaO2≥90%,
respiratory rate <30/min and haematocrit ≥30%
 Ensure antibiotics are given within one hour of presentation, after taking blood
for culture: ampicillin 1-2 g IV 6 hourly with gentamicin 240 mg IV daily, and
metronidazole 400 mg orally 8 hourly, or broad-spectrum alternatives
 Observe hourly fluid intake and output, heart rate, SaO2, respiratory rate, and
BP for the first 24-48 hours, reducing to 4 hourly with clinical improvement
 Fluid orders depend on hydration and ability to take orally – adjust to U&E
and urine output, writing up fluids clearly including time when each infusion
should be completed. Only write in mL/hour if in a high care area
 Perform uterine evacuation if there are retained products
 Consider laparotomy with hysterectomy, and transfer to intensive care if:

- There is generalised peritonitis

- Pus or frank blood is withdrawn on paracentesis colpopuncture
- There is evidence of septic shock not responding to fluid management
- There is dysfunction of two organ systems other than the core 1
- There is no improvement after 24-48 hours of treatment

CAESAREAN SECTION WOUND SEPSIS

This usually presents 4-10 days after the operation. The wound is tender and
indurated, and pus may be expressed from the suture line.

Management

 Assess for severe sepsis and manage accordingly if present (above)

 Open the wound and remove sutures from the skin and subcutaneous tissue
 Aspirate tender or fluctuant areas with a needle and syringe and send blood
or pus for MCS. Do not send pus swabs
 Subcutaneous abscesses may be drained using local and/or opiate analgesia
 Inspect the depth of the wound – if the rectus sheath is not intact:
- If the bowel is visible arrange laparotomy and possible hysterectomy
- If the peritoneal cavity appears to be sealed off, do an abdominal
ultrasound scan. In the absence of fluid collections or clinical peritonitis,
laparotomy is not necessary at this stage
 Add cloxacillin 500 mg oral/IV 6 hourly to the antibiotic regimen
 Order wound dressings as appropriate for the dressing method used
 62

Severe wound sepsis and necrotizing fasciitis

 Signs of severe wound sepsis or underlying necrosis include:

- Persistent pyrexia despite opening of the wound and other causes
excluded
- Skin blisters overlying the indurated tissue
- Severe wound hyperaesthesia (extremely tender on gentle touch of intact
tissue)
 If a wound is frankly necrotic and ulcerating, urgent debridement in theatre is
indicated, with prior ultrasound to assess the abdomen for laparotomy
 Debrided necrotic tissue must be sent for MCS
 After debridement, leave the wound open, and pack with swabs soaked with
metronidazole and gentamicin, and covered with Op-site dressing

LACTATION AND LACTATION SUPPRESSION

In general, breastfeeding can be encouraged for all mothers, including those who
are HIV infected after appropriate counselling

 Wherever possible, avoid separation of a mother from her newborn baby

 Encourage early suckling (within 1-2 hours of birth)
 Ensure correct positioning of the infant during suckling
 Avoid formula, water or other oral supplementation of healthy newborns
 Encourage unrestricted (‘demand’) breastfeeding
 Avoid prescribing combined oral contraceptives to women who want to
breastfeed – give progestin-only preparations

Insufficient milk supply

1. Ensure correct positioning of the infant during suckling

2. Encourage unrestricted breastfeeding
3. Encourage adequate fluid intake
4. Avoid the temptation to supplement the infant
5. Provide emotional and practical support
6. If true milk insufficiency is suspected, prescribe domperidone, if available, 10
mg orally 3 times daily, or metoclopramide 10 mg orally 3 times daily for 7-10
days then taper off for one week
7. Consider Sheehan’s syndrome (pituitary failure seconday to postpartum
haemorrhage and hypovolaemic shock) if there appears to be no milk at all
 63

Breast engorgement

1. Ensure correct positioning of the infant during suckling

2. Encourage unrestricted breastfeeding
3. Give analgesia, e.g. paracetamol 1 g orally 6 hourly
4. Express the breast(s) if engorgement is severe, and give cold compresses,
e.g. with fresh cabbage leaves
5. If infective mastitis is suspected, prescribe broad spectrum antibiotics
including cover for Staphylococcus aureus (flucloxacillin 500 mg orally 6
hourly)

Painful cracked nipples

1. Give analgesia, e.g. paracetamol 1 g orally 6 hourly

2. Continue breastfeeding with the unaffected breast
3. Suspend feeding with the affected breast, but express at regular intervals
4. Resume feeding when the cracks have started to heal
5. Ensure correct positioning of the infant during suckling

Lactation suppression

Women may request assistance to suppress milk production. This may be

because of HIV, perinatal death, or their own choice on infant feeding. Breast
engorgement is the main problem in postpartum women who do not breastfeed.

 The breasts must not be expressed except to release small amounts of milk if
needed, only to reduce discomfort
 A firm bra, cold compresses with cold cabbage leaves, and paracetamol 1 g
orally 4 times daily, may provide relief for engorged breasts
 Bromocriptine 2.5 mg orally 12 hourly for two weeks is effective
 Bromocriptine may cause nausea, dizziness, drowsiness, rebound lactation,
and, rarely, acute severe hypertension, thromboembolism, myocardial
infarction and stroke
 Avoid bromocriptine in women with hypertension or other cardiovascular
disease
 Cabergoline 1 mg orally as a single dose, is as effective and has fewer side
effects than bromocriptine
 64

Chapter 3 Hypertension in pregnancy

Hypertensive disorders of pregnancy are a frequent cause of maternal mortality
in South Africa. Early detection and timely intervention are essential to prevent
maternal and perinatal complications.

DEFINITIONS

Definition of hypertension

A systolic BP ≥140 mmHg or a diastolic BP ≥90 mmHg, on 2 occasions ≥4 hours

apart, or a single BP ≥160/110 mmHg

Definition of proteinuria

The presence of ≥1+ proteinuria on reagent strip (dipstick) testing on 2 clean

catch urine specimens taken ≥4 hours apart, or protein excretion 300 mg in a 24
hour specimen of urine

Definitions of hypertensive disorders of pregnancy

Essential hypertension: hypertension without proteinuria, diagnosed before 20

weeks of pregnancy, or a history of essential hypertension prior to the pregnancy

Chronic renal disease: hypertension with proteinuria, diagnosed before 20

weeks of pregnancy, or a history of chronic renal disease prior to the pregnancy

Pre-eclampsia (gestational proteinuric hypertension, pre-eclamptic toxaemia):

hypertension, detected after 20 weeks of pregnancy with any of the following:

 Proteinuria
 Renal insufficiency - serum creatinine ≥100 µmol/L
 Liver disease - AST or ALT >40 U/L
 Neurological problems – severe headache, hyperreflexia, convulsion
 Thrombocytopaenia <100 x 109/L or haemolysis
 Placental insufficiency – asymmetric IUGR

Gestational hypertension: hypertension without proteinuria or any features of

pre-eclampsia, detected after 20 weeks of pregnancy

Unclassified hypertension: hypertension detected in a woman in whom the BP

was not measured before 20 weeks of pregnancy. This may present as pre-
eclampsia or as apparent gestational hypertension
 65

Superimposed pre-eclampsia: pre-eclampsia that develops in a woman with

chronic hypertension

GRADES OF PRE-ECLAMPSIA

Severe pre-eclampsia: pre-eclampsia, with a systolic BP ≥160 mmHg or a

diastolic BP ≥110 mmHg measured on 2 occasions ≥4 hours apart, or a diastolic
BP ≥120 mmHg, or organ dysfunction irrespective of the level of BP, e.g. renal
dysfunction, raised liver enzymes or thrombocytopaenia

Mild pre-eclampsia: pre-eclampsia that is not severe

Imminent eclampsia: symptoms and signs that develop in a pre-eclamptic

woman: severe headache, visual disturbances, epigastric pain, hyperreflexia,
dizziness and fainting, vomiting

Eclampsia: generalized tonic-clonic seizures after 20 weeks of pregnancy and

within 7 days after delivery, associated with hypertension and proteinuria, in the
absence of other causes of convulsions

HELLP syndrome: the presence of Haemolysis, Elevated Liver enzymes and

Low Platelets, almost always in association with hypertension and proteinuria

MEASUREMENT OF BLOOD PRESSURE IN PREGNANCY

 The right and left semi-lateral, and sitting positions are acceptable. The
supine position (lying flat on the back) should not be used after 24 weeks

 The sphygmomanometer cuff must be at the level of the heart

 A “large adult” cuff must be used for an arm with a circumference ≥34 cm,
and an “adult thigh” size cuff must be used for an arm circumference ≥44 cm

 The diastolic BP is taken at the point where the sounds disappear (Korotkoff
phase 5). In women where the sounds do not disappear, the point of muffling
(Korotkoff phase 4) is used.

 A mercury sphygmomanometer is preferred, because automated devices may

under-record the BP in pregnant women
 66

PATHOPHYSIOLOGY OF PRE-ECLAMPSIA

Pre-eclampsia is a multiorgan endothelial disease affecting predominantly the

circulatory, renal, central nervous, coagulation, liver and uteroplacental systems.
A poorly understood placental defect causes an angiogenic factor imbalance,
which affects the endothelium (lining) of maternal blood vessels, resulting in
vascular spasm, platelet aggregation and leakage of plasma from capillaries.
Pre-eclampsia complicates 5-8% of pregnancies in South Africa. There is no
effective method of prevention, and the only known cure is termination of
pregnancy. Early detection, treatment and follow up may help in reducing death
and morbidity from complications of pre-eclampsia.

COMPLICATIONS OF PRE-ECLAMPSIA

Maternal

 Cerebrovascular accident
 Eclampsia
 Pulmonary oedema
 Renal failure
 Liver failure or liver haemorrhage
 Disseminated intravascular coagulation
 Abruptio placentae
 HELLP syndrome (haemolysis, elevated liver enzymes, low platelets)

Fetal/neonatal

 Intrauterine death from placental insufficiency

 Intrauterine death from abruptio placentae
 Intrauterine growth restriction
 Prematurity

MANAGEMENT OF HYPERTENSIVE DISORDERS OF PREGNANCY

ANTENATAL VISITS

Chronic and nonproteinuric hypertensives should attend 4 weekly up to 28

weeks, 2 weekly up to 36 weeks and weekly up to delivery. Women with pre-
eclampsia must be admitted to hospital.

PREVENTION OF PRE-ECLAMPSIA

Give aspirin 100 mg orally daily from 12 weeks’ gestation to women with a history
of previous pre-eclampsia.
 67

HOSPITAL ADMISSION

Mandatory independent admission criteria for hypertensive patients

 Proteinuria ≥1+ on a midstream specimen

 Symptoms of imminent eclampsia
 Organ dysfunction e.g. thrombocytopenia, liver dysfunction, eclampsia
 Diastolic BP 110 mmHg
 Systolic BP 160 mmHg
 Antepartum haemorrhage
 Pregnancy at ≥37 weeks

Admission procedure

1. Take blood for FBC and U&E

2. Order 4 hourly BP and daily urinalysis for protein
3. Order NST to be done in the ward if fetus is viable (≥26 weeks)
4. Order ultrasound with fetal weight estimation, with umbilical artery Doppler
studies if gestation <34 weeks
5. Prescribe oral antihypertensive medication
6. If BP 160/110 mmHg, treat as for severe pre-eclampsia (see below)

INPATIENT MANAGEMENT OF MILD HYPERTENSION OR PRE-ECLAMPSIA

 Doctors' daily round - ask for symptoms of imminent eclampsia, fetal

movements, check BP and urine chart, and adjust medication if needed
 Repeat U&E and FBC twice weekly
 Send urine for spot protein:creatinine ratio if urinalysis findings are equivocal
 Send urine for microscopy for casts, and for 24-hour protein estimation if
renal disease is suspected
 Do NST on alternate days (if gestation ≥26 weeks)

Treat imminent eclampsia and severe pre-eclampsia as set out below

Discharging hypertensive pregnant patients from the antenatal ward

 The BP must be stable at <160/110 mmHg

 There must be no proteinuria
 The pregnant woman and fetus must both be in generally good condition
 There must be no indication for delivery
 Ensure antihypertensive medication is prescribed
 A return date to antenatal clinic must be given
 A brief discharge summary must be written on the antenatal record
 68

CONTROLLING THE BLOOD PRESSURE IN PRE-ECLAMPSIA

Emergency treatment (BP 160/110 mmHg)

 Admit to a high care area

 Preload with 300 mL Ringer-Lactate solution over 20 minutes
 Give nifedipine 10 mg orally as a single dose unless heart rate ≥120/min
 Consider adding magnesium sulphate
 Measure the BP every 30 minutes at first, then hourly
 Repeat nifedipine ½ hourly if necessary (BP still ≥160/110 mmHg)
 Aim for a BP of 140/90 mmHg
 Add maintenance treatment (below)

For unconscious or tachycardic patients, infuse labetalol 200 mg in 200 mL

normal saline at 20 mL/hour (i.e. 20 mg/hour, increasing by 20 mg/hour every 30
minutes if necessary, to a maximum of 300 mg in 24 hours). Give 300 mL
preload just before starting the infusion. A 20 mg starting bolus may be given.

Maintenance treatment (BP 150/100)

The drugs are usually prescribed in a stepwise fashion, depending on response.

Aim for a BP of 130-149/90-99 mmHg

 Step 1: Methyldopa 500 mg orally 12 hourly up to a maximum of 750 mg 8

hourly
 Step 2: Add amlodipine 5 mg daily, up to a maximum of 10 mg daily
 Step 3: Add hydralazine 10-50 mg orally 8 hourly
 Step 4: Consider delivery

For chronic hypertensive patients, discontinue beta-blockers, diuretics, and

angiotensin converting enzyme inhibitors. Some chronic hypertensive women
may not need any medication during pregnancy, because of the physiological fall
in blood pressure
 69

INDICATIONS FOR DELIVERY OF HYPERTENSIVE WOMEN

Pregnancy at 37-40 weeks with gestational and essential hypertension

Pregnancy 37 weeks with mild pre-eclampsia
Pregnancy 34 weeks in severe pre-eclampsia
Estimated fetal weight 1.5 kg in severe pre-eclampsia
Pregnancy ≤24 weeks or fetus <600 g in severe pre-eclampsia
Eclampsia
Imminent eclampsia persisting after treatment with magnesium sulphate
Cerebral oedema
HELLP syndrome
Renal dysfunction (serum urea 8 mmol/L, creatinine 100 µmol/L, urine output
<500 mL/24 hours)
Thrombocytopaenia (platelet count persistently <100109/L)
Intrauterine growth restriction
Fetal distress
Dead fetus
Abruptio placentae

SEVERE PRE-ECLAMPSIA

Initial management is as follows:

1. Arrange for transfer to a high care area

2. Insert a urinary catheter and monitor urine output hourly
3. Take blood for FBC, U&E, and AST. Do INR if there is thrombocytopaenia as
caesarean section may need to be done
4. Assess gestational age and fetal weight by ultrasound, with umbilical artery
Doppler studies at <32 weeks
5. If 24-33 weeks, give betamethasone 12 mg IMI stat, repeat after 12 hours
6. Do CTG if fetus is viable (≥26 weeks)
7. Treat the high BP
8. Arrange for delivery if indications exist and notify paediatricians if the baby is
expected to weigh <1500 g.
9. If not for delivery, adjust oral antihypertensive medication
10. Discharge from high care area, remove IV lines and continue conservative
management in the antenatal ward (below)
11. Always consider other causes of hypertension e.g. phaeochromocytoma

Exception: Asymptomatic chronic hypertensive patients <20 weeks pregnant

can be managed in the antenatal wards without IV lines and catheters.
 70

Conservative management of severe pre-eclampsia (24-33 weeks)

Following stabilisation of BP:

 Continue oral antihypertensive medication

 Twice weekly FBC, U&E, AST, more frequently if necessary
 6 hourly NST if possible
 Ultrasound fetal assessment for liquor volume and umbilical artery Doppler
studies every 2 weeks
 4 hourly BP, and daily urinalysis for protein

HELLP syndrome

 Initial management is as for severe pre-eclampsia

 In women <34 weeks, plan for delivery within 24-48 hours to allow
betamethasone to take effect
 Deliver as soon as possible if <26 weeks or ≥34 weeks
 If platelet count is <50 x 109/L and caesarean section is planned, give platelet
transfusion 1 megaunit at operation

ECLAMPSIA

Principles of care are control of convulsions, reduction of BP, clinical and

laboratory assessment, and delivery

Immediate management of eclampsia

1. Call for help

2. Turn the woman onto her side (left lateral)
3. Clear the airway – ensure that it is open and remove secretions or vomitus
4. Give oxygen by mask
5. Prevent injuries, e.g. use cot sides, and remove sharp objects
6. Insert an oropharyngeal airway if necessary
7. Start an intravenous drip and give magnesium sulphate
8. With persistent convulsions or restlessness, give additional magnesium
sulphate 2 g IV or clonazepam 1 mg IV over 5 minutes
9. Phenytoin has no role in the prevention or management of eclamptic
convulsions
10. Insert a urinary catheter
11. Admit to a high care area

Management of eclampsia after fits have been controlled

1. Take blood for FBC, U&E, AST and INR

2. Treat the BP if 160/110 mmHg
 71

3. Continue intravenous fluids (Ringer-Lactate or normal saline) at 70 mL/hour

4. Monitor BP, urine output and level of consciousness hourly
5. Monitor level of consciousness 2 hourly using GCS or AVPU
6. Intubate if GCS ≤8 or responding only to pain
7. Assess fetal condition with CTG, and fetal size by ultrasound
8. Continue magnesium sulphate infusion at 1 g/hour until 24 hours after
delivery or 24 hours after the last convulsion, whichever is later, in a high care
area
9. Deliver the baby as soon as possible (maximum 12 hours) after the first fit:
- By caesarean section if there is fetal distress or the cervix is unfavourable
- Vaginally if the woman is in labour or if the cervix is favourable for
induction (soft, 2-3 cm dilated, fully or almost fully effaced)
10. Vacuum extraction or forceps delivery may be necessary in the second stage
11. Do not use ergometrine in the third stage (use oxytocin 10 units IM)
12. Expect return to full consciousness within two hours of the last fit
13. Investigate women with persistent coma or localising signs – call a
neurologist to assess and arrange for a computerized tomography (CT) scan
of the brain
14. Take blood for FBC and U&E on the day after delivery
15. Keep in hospital for at least 3 days after delivery

The Glasgow Coma Scale

Eyes 4 Open spontaneously (already open with blinking)

3 Open to speech
2 Open to pain
1 No response

5 Orientated to time and place

Verbal 4 Confused (still answers questions)
(exclude if intubated) 3 Inappropriate words (recognizable but random)
2 Incomprehensible sounds
1 None

6 Obeys command (no pain required)

5 Localises to pain
Motor 4 Withdraws (pulls away from a painful stimulus)
3 Decorticate response (abnormal flexion)
2 Decerebrate response (extensor response)
1 No movement
 72

IMMINENT ECLAMPSIA

1. Exclude other causes of headache or abdominal pain – abruptio placentae,

simple headache, and send to a high care area. Give paracetamol 1 g orally
2. Insert an intravenous drip, give magnesium sulphate (below) and treat the
hypertension if BP ≥150/100 mmHg
3. Insert a urinary catheter and monitor urine output hourly
4. Take blood for U&E, FBC
5. Run intravenous fluids at 70 mL/hour
6. Do CTG
7. Reassess hourly. If imminent eclampsia persists, arrange for delivery

GIVING MAGNESIUM SULPHATE*

Loading dose: Add magnesium sulphate 4 g to 200 mL normal saline and run
the infusion rapidly.

Maintenance dosage: Add magnesium sulphate 10 g to 200 mL normal saline

and run the infusion at 20 mL/hour, equivalent to 1 g/hour.

Alternative regimen: Dilute magnesium sulphate 4 g (8 mL) in 12 mL saline and

give IV over 4 minutes, with 5 g IM in each buttock with 1 mL 1% lidocaine (total
14 g). Maintenance is 5 g IM 4 hourly, in alternate buttocks, with lidocaine.

Precautions during magnesium sulphate infusion

Maintenance doses should only be continued if the following hourly observations

are made and confirmed:

 Presence of patellar reflexes,

 The respiratory rate is 12 breaths/minute, and
 Urine output is 100 mL in the last 4 hours

Treatment of suspected overdose

 The symptoms and signs of overdose are a feeling of extreme weakness,

decreased respiratory rate, and absent tendon reflexes
 Take blood for magnesium level
 Give 10% calcium gluconate 10 mL IV slowly, then observe closely

Blood magnesium levels:

Normal range 0.7-1.0 mmol/L, therapeutic at 1.25-3.25, absent reflexes at 4-5,

respiratory depression at 6-8, cardiac arrest at >15 mmol/L
 73

LABOUR AND DELIVERY IN HYPERTENSIVE DISORDERS

INDUCTION OF LABOUR

The usual methods of induction may be used: take great care during induction of
labour in severe pre-eclampsia, especially preterm and with oligohydramnios or
suspected IUGR. CTG monitoring is mandatory.

LABOUR

 Admit to a high care area

 Give total fluids 70 mL/hour
 Run continuous CTG
 If oxytocin is used, give it from a 200 mL bag of normal saline
 Do assisted delivery if BP 160/110 in the second stage or if the woman
cannot push
 Ergometrine is contraindicated in the third and fourth stages
 If caesarean section needs to be done, please note pre-anaesthetic tests
(page 42)

POSTPARTUM CARE

 Keep the woman in hospital for at least 24 hours after delivery

 Continue oral antihypertensive medications (e.g. methyldopa) and modify or
reduce the dosage as necessary
 Diuretics, e.g. hydrochorothiazide 25 mg daily, may be restarted or given to
women with chronic hypertension
 Treat a BP 160/110 with nifedipine 5-10 mg orally as a single dose, and
prescribe amlodipine 5 mg daily, or increase the current dose to 10 mg daily
Measure the BP hourly until stabilized
 Discharge the woman from hospital if the BP is <160/110 for 24 hours
 Write a referral note to the local clinic for a woman discharged on
antihypertensive medication to attend there after 2 weeks for BP
measurement and adjustment (or discontinuation) of therapy
 74

Chapter 4 Common obstetric problems

INTRAUTERINE GROWTH RESTRICTION

Intrauterine growth restriction (IUGR) refers to the failure of a fetus to achieve its
growth potential. IUGR can be classified into 2 main groups:

 Symmetric – both the head and body show growth failure. This may result
from genetic or chromosomal defects, intrauterine infection, or exposure to
teratogens. Ultrasound may reveal structural abnormalities. Some fetuses
may appear symmetrically growth impaired, but are normal small babies, or
may be suspected to be small because of wrong pregnancy dates.

 Asymmetric – the head continues to grow, but the body shows growth
deceleration. This may result from pre-eclampsia, vascular disease (as in
diabetes or lupus), or from isolated placental insufficiency. Ultrasound
findings are those of placental insufficiency, such as oligohydramnios and
abnormal Doppler wave-forms (umbilical vessels, middle cerebral artery,
ductus venosus)

In a nutshell

 When both the anomaly scan and umbilical artery waveforms are normal, the
small fetus should be classified as a ‘normal small fetus’
 When the anomaly scan is abnormal and the waveforms are normal, the fetus
is an ‘abnormal small fetus’– symmetric IUGR
 When the anomaly scan is normal and Doppler waveforms are abnormal,
there is asymmetric IUGR

Factors causing growth restriction

Fetal factors Maternal factors

Chromosomal Constitutional
Congenital infection Nutrition
Genetic syndromes Genetic (e.g. phenylketonuria)
Multiple gestation Hypertension, current or previous
Cardiac disease
Placental factors Autoimmune disease
Diabetes mellitus
Abnormal trophoblast invasion Kidney disease
(e.g. pre-eclampsia) Medication
Abnormal cord insertion Smoking, alcohol and recreational drugs
Placental lakes Exposure to toxins
Placental location (e.g. praevia) Residence at high altitude
Tumors
 75

Pathophysiology of impaired placentation in asymmetric IUGR

1. There is minimal or no trophoblastic invasion into maternal uterine spiral

arteries beyond the decidual-myometrial junction. Cellular mechanisms may
involve reduced trophoblast motility, increased trophoblast apoptosis, altered
natural killer cell function, and endothelial cell interaction
2. This results in failure of conversion of the small muscular spiral arteries into
large vascular channels: the uteroplacental circulation cannot then develop
into a healthy low-resistance-to-flow system
3. The consequence is placental insufficiency and/or pre-eclampsia, with fetal
growth restriction

SCREENING FOR IUGR

Methods to identify women at risk for IUGR include the following:

 Antenatal history-taking and assessment for factors listed in the above

 First-trimester ultrasound screening at 11-14 weeks for fetal abnormalities

and for uterine artery Doppler indices as for pre-eclampsia screening

 Third-trimester symphysis-fundal height measurement and uterine palpation

to identify the small-for-dates uterus

Diagnosis and follow-up

Ultrasound scanning is done to confirm IUGR based on biometry and umbilical

artery Doppler indices.

 If the umbilical artery resistance index is abnormally increased, consider

delivery if estimated fetal weight ≥1.5 kg or gestation ≥34 weeks, otherwise
follow up with weekly middle cerebral artery pulsatility indices (MCA PI) as
long as these remain normal. Give betamethasone to accelerate lung maturity
 If middle cerebral artery indices are abnormal, admit to hospital for twice-
weekly ductus venosus Doppler and daily NST
 Deliver if the ductus venosus Doppler is abnormal or the NST is pathological
 Individualise management with estimated fetal weight <900 g
 76

Fetal weight ≥1500 g Asymmetric IUGR

or gestation ≥34 with abnormal
weeks: consider umbilical artery
delivery Doppler

Middle cerebral
artery Doppler

Abnormal Normal

Ductus venosus Follow up weekly

Doppler with serial scans for
growth and Dopplers

Normal Abnormal

Follow up with twice-

weekly Dopplers and
daily NSTs
Fetal weight ≥900 g Fetal weight <900 g

Deliver by caesarean Continue observation

section Consider delivery if
NST abnormal
Individualize

MANAGEMENT OF IUGR
IN THE PRESENCE OF
ABNORMAL UMBILICAL
ARTERY DOPPLER
 77

Timing of delivery with IUGR in the presence of pre-eclampsia

 If fetus ≥1.5 kg (≥34 weeks) give betamethasone and consider delivery

 From 32-34 weeks factors such as availability of neonatal services are
important points when making a decision
 From 26-32 weeks, follow with multivessel Doppler studies and NSTs
 In cases of severe pre-eclampsia, the maternal condition precludes fetal
observation and may necessitate delivery in the woman’s interest

Mode of Delivery

 Maternal well-being must be balanced against the likely neonatal outcome

 Caesarean section in the baby’s interest can rarely be justified as a means of
delivery at ≤24 weeks’ gestation because of the poor neonatal prognosis.
If the parents insist on caesarean section, seek a second senior opinion
 In the presence of a reassuring NST, vaginal delivery is generally preferable
with continuous CTG in labour, but at gestation <32 weeks, caesarean
section may be preferred as the success rate of induction is reduced.

INTRAUTERINE FETAL DEATH

Typical clinical findings of intrauterine fetal death (IUFD) include:

 Absent fetal movements

 Disappearance of symptoms of pregnancy
 Symphysis-fundal height not increasing as expected
 Fetal heart not heard

The diagnosis is confirmed by ultrasound scan. Be compassionate, offer a repeat

scan by a second health care worker. Take a good history to help establish the
cause of fetal death. Offer induction of labour, although the woman may choose
to go home and return later.

Investigations
Take blood for FBC, urea & electrolytes, INR & screen for antiphospholipid
syndrome (Antinuclear factor, Anticardiolipin antibody, Lupus anticoagulant &
anti-B2 glycoprotein 1 antibody). Check RPR, Rh & HIV if not done previously.

INDUCTION, LABOUR AND DELIVERY

 Oxytocin infusion may be used if the cervix is favourable

 Intravaginal misoprostol may be used:
- At 20-24 weeks, give 100 mcg 6 hourly, up to 4 doses
- At ≥26 weeks: 25-50 mcg 4-6 hourly, up to 6 doses
 78

- Alternatively from 26 weeks onwards, dissolve 200 mcg misoprostol in 200

mL water, and give 20 mL (20 mcg) every 2 hours orally
 Do not use misoprostol with parity ≥5 or previous caesarean section beyond
24 weeks gestation
 Do not infuse oxytocin <6 hours after the last dose of intravaginal misoprostol
 Bulb induction using a Foley catheter is a safe alternative to misoprostol –
inflate a 30 mL Foley catheter bulb with 50 mL water, place above the internal
os and strap the catheter to the thigh
 If induction fails, consider the possibility of extrauterine pregnancy
 Give analgesia – morphine 0.1 mg/kg IM (maximum 10 mg) with
metoclopramide 10 mg IM 4 hourly if necessary
 Avoid artificial rupture of membranes, except with abruptio placentae
 Labour management follows the same principles as for normal labour: enter
all observations, fluids and medications on a partogram, and treat labour
abnormalities appropriately

POSTPARTUM CARE

 Encourage the parents to hold and name at their baby

 Be sympathetic and supportive at all times, note the normal grief responses
 Explain the cause of the stillbirth (if known) to the parents
 Offer the parents the opportunity to take photographs of their baby
 Advise on lactation suppression (give carbegoline 1 mg stat, oral)
 Transfer the mother to a gynaecology ward, or a separate area in the
postnatal ward

Investigations following an unexplained IUFD

 Examine the placenta and make appropriate notes

 A paediatric doctor must examine the baby and make appropriate notes
 The mother must not be discharged without Rhesus group and RPR results
 Further investigations and autopsy, if needed, are discussed on page xx

ANTEPARTUM HAEMORRHAGE

Antepartum haemorrhage (APH) is defined as bleeding from the genital tract

from 26 weeks of pregnancy or from fetal viability, up to delivery of the baby.

CAUSES

 Placental – abruptio placentae, placenta praevia, vasa praevia

 Non-placental – vaginal and cervical lesions including cancer, cervical
infections, trauma (including uterine rupture) and decidual bleeding
 Unknown – APH of unknown origin (APHUO)
 79

All APH cases are regarded as obstetric emergencies until assessed

EMERGENCY MANAGEMENT OF APH

1. Start an intravenous infusion of Ringer-Lactate solution with a large bore

(16G) intravenous cannula
2. If the woman is in shock, insert a second IV line and resuscitate with 1-2 L of
Ringer-Lactate. Take blood for haemoglobin and cross-match
3. Do not perform a digital vaginal examination, unless placenta praevia has
been ruled out by a previous ultrasound scan
4. Do an ultrasound scan to look for placenta praevia, to estimate fetal weight,
identify a fetal heart beat and to demonstrate retroplacental clot (not always
visible on ultrasound in abruption placentae)
5. If no placenta praevia, examine the cervix by vaginal speculum and by digital
examination for dilatation, presenting part and a local lesion
6. Further management depends on the cause (below)

Differences between abruptio placentae and placenta praevia

Abruptio placentae Placenta praevia

Patient Frequently hypertensive Frequently previous

caesarean section

Symptoms Pain almost always Usually painless. Fetal

present. Fetal movements movements usually normal
may be absent or reduced

Abdominal Hard, tender uterus, large Soft, nontender uterus,

examination for expected dates often with malpresentation
or high presenting part

Bleeding Dark blood with clots, at Bright red blood

times no external bleeding

Ultrasound Fetus may be dead, Placenta implanted close to

placenta normally situated. or over the cervix
Retroplacental clot may or
may not be visible
 80

Antepartum haemorrhage

Ringer-Lactate IV
infusion
Assess blood loss
Check fetal heart

Abdominal
examination
Ultrasound
examination

Consider:

 Is there maternal
compromise?
 Is there fetal distress?
 Is the fetus mature?
 Is the fetus normal?
 Is the woman in labour?

Placenta Abruptio Exclude

praevia placentae uterine rupture

No cause found
MANAGEMENT AND
DIAGNOSIS OF
ANTEPARTUM
Speculum
examination HAEMORRHAGE

APH of Cervical or
unknown origin vaginal lesion
 81

PLACENTA PRAEVIA

Placenta praevia may be major, with placenta covering the internal os, or minor,
with placenta in front of the presenting part but not covering the os. Major
placenta praevia may require caesarean section well before term, while the
occasional woman with minor placenta praevia may do well with vaginal delivery.
Principles of care are similar for both degrees.

At <37 weeks:

 Admit to hospital; do not discharge patients with major placenta praevia

 Check Hb
 Ensure that blood is available for transfusion
 If <34 weeks, give betamethasone 12 mg IM 12 hourly for 2 doses
 Perform CTG on admission and ask about fetal movements daily
 Plan elective caesarean section at 35-37 weeks
 Perform emergency caesarean section if transfusion becomes necessary, or
if bleeding is considered to be severe, or if there is fetal distress
 With spontaneous labour/miscarriage at <26 weeks, aim for vaginal delivery

At 37 weeks or more, or in labour:

 If, on ultrasound, the placenta covers the cervix, perform caesarean section
 If the placenta does not cover the cervix, perform vaginal examination in
theatre (with theatre staff and anaesthetist in attendance) and proceed
immediately with caesarean section if the placenta can be felt next to or
through the cervix. If the placenta cannot be felt, and the cervix is sufficiently
open and effaced (favourable), rupture the membranes and induce labour
 Caesarean section for placenta praevia may result in severe haemorrhage.
Be prepared to give blood transfusion, insert haemostatic sutures, use a
balloon or do hysterectomy. Inform the woman of these when taking consent.

ABRUPTIO PLACENTAE

Abruptio placentae is associated with pre-eclampsia: the BP may be normal or

high even in the presence of clinical shock. Proteinuria is an indicator of
underlying pre-eclampsia in women with abruptio placentae.

If the fetus is alive:

 With expected weight >900 g, perform emergency caesarean section, unless

delivery is imminent (cervix 8 cm dilated) and there is no fetal distress

 With expected weight <900 g, rupture the membranes and augment labour
with oxytocin. Monitor blood loss carefully
 82

If the fetus is dead:

Urgent delivery is essential, but vaginal birth is preferred. With a dead fetus, the
abruption is likely to be severe and requires close observation and frequent
reassessment.

Consider uterine rupture, which may mimic abruptio placentae as a cause

of APH with fetal death. If suspected, resuscitate and arrange laparotomy.

1. Admit to a high care area

2. Take blood for cross-match, FBC, U&E, INR and fibrinogen degradation
products (FDP)
3. Blood transfusion (2-4 units) is usually necessary, with fresh frozen plasma if
there is a clotting disorder. If the platelet count is <50109/L, transfuse 1
megaunit of platelets
4. Consider insertion of a central venous pressure (CVP) line for patients who
are haemodynamically unstable or who have severe pre-eclampsia
5. Insert a urinary catheter and monitor hourly urine output
6. Give fluids to maintain a systolic BP 100 mmHg, or a CVP of 6 cm water
7. Rupture the membranes and augment labour with oxytocin
8. Aim for induction-to-delivery interval of ≤12 hours
9. Give analgesia - morphine 0.1 mg/kg IM (maximum 10 mg) with
metoclopramide 10 mg IM 4 hourly
10. Caesarean section is indicated if:
- The cervix is closed and the membranes cannot be ruptured
- There is life-threatening haemorrhage at less than full cervical dilatation
11. After delivery of the fetus and placenta, run a drip with oxytocin 20 units in 1L
Ringer-Lactate to prevent postpartum haemorrhage, and observe closely for
bleeding. Inspect the lower genital tract for bleeding lacerations
12. Check FBC and U&E on the day after delivery

ACUTE KIDNEY INJURY

There is oliguria (<500 mL/24 hours) with rising serum urea and creatinine levels.
Abruptio placentae is the most common obstetric cause, but this may also result
from severe pre-eclampsia, severe haemorrhage, and severe sepsis.
The principles of management are as follows:

1. Correct fluid deficit with intravenous crystalloids, with a CVP line if necessary
2. Strict intake and output chart: total fluids given should be previous day’s
output, plus 500 mL for insensible loss
3. Take blood daily for U&E and FBC
4. Call for a renal specialist opinion if renal function worsens. Indications for
dialysis include rapidly rising urea and creatinine levels, pulmonary oedema,
hyperkalaemia, severe acidosis, and clinical evidence of uraemia
5. Avoid giving diuretics or dopamine unless instructed by renal specialists
 83

VASA PRAEVIA

Vasa praevia is the presence of fetal blood vessels in the placental membranes
below the level of the presenting part, as a result of velamentous cord insertion.
This rare condition is associated with placental abnormalities, multiple pregnancy
and low-lying placenta. Vasa praevia can be detected antenatally by vaginal
ultrasound with colour Doppler studies, or during labour by palpating blood
vessels on the membranes during vaginal examination. These blood vessels may
be torn when the membranes rupture, resulting in severe fetal bleeding that
presents as APH.

Suspect vasa praevia as a cause of APH with:

 Passage of dark blood from the vagina after membrane rupture

 Blood loss <300 mL
 Low-lying placenta, multiple pregnancy or placental abnormality
 No maternal haemodynamic abnormality
 Fetal heart rate abnormalities on CTG

The only treatment to save the baby’s life is immediate delivery, vaginally or by
caesarean section

ANTEPARTUM HAEMORRHAGE OF UNKNOWN ORIGIN

In this condition, there is no evidence of abruptio placentae, placenta praevia, or

local lesions. APHUO must be distinguished from show (mucus, no clots) and
from cervical or decidual bleeding during vaginal examination.

 Admit to hospital
 At 37 weeks pregnant, induce labour
 If <37 weeks pregnant:

- Do daily CTG
- Observe for symptoms and signs of abruptio placentae
- Discharge from hospital 24-48 hours after bleeding has stopped
- Assess the cervix before discharge to exclude imminent preterm labour
- Continue antenatal care at hospital, with attention to fetal growth and fetal
movements
- Consider induction of labour at 38-40 weeks
 84

MULTIPLE PREGNANCY

Multiple pregnancy is frequently suspected on clinical examination, but is

diagnosed by ultrasound scan. Request ultrasound assessment for pregnancies
with the following signs:

 Symphysis-fundal height >90th centile for gestational age

 An unusually wide and round uterus
 Impression of increased liquor volume
 More than 2 fetal poles palpable
 Head feels smaller than expected for the uterine size

Ideally, multiple pregnancies should be detected at a routine 11-14 week scan,

where gestational age, chorionicity and Down’s syndrome risk can be assessed.

Chorionicity on ultrasound

 Dichorionic twins may be of different sexes with separate placentas and a

‘lambda’ sign at <24 weeks if there is a single placenta

 Monochorionic twins are always same-sex with a single placenta, and usually
a ‘T’ sign at <24 weeks. Subsequent ultrasound scans include assessment for
twin-to-twin transfusion syndrome

 Chorionicity is undetermined if the twins are same-sex and there is a single

placenta at ≥24 weeks. This is managed as for monochorionic twins

ANTENATAL MANAGEMENT

 All antenatal visits must take place at a referral centre or specialized clinic
 Warn the woman of possible complications: preterm labour, anaemia,
hypertension and general discomfort
 Advise the woman to monitor fetal movements
 Monitor SFH, expected at >90th percentile
 Repeat Hb at 28, 32 and 36 weeks
 Give ferrous fumarate 200 mg orally 8 hourly to treat anaemia
 If there are no complications, follow up every 4 weeks to 28 weeks, then
every 2 weeks
 Perform ultrasound scan every 4 weeks from 28 weeks
 Refer for fetal medicine unit assessment if there is discordant growth (smaller
twin >25% lighter than larger twin), single fetal death, or suspected twin-to-
twin transfusion syndrome
 85

DELIVERY

 For dichorionic twins, plan vaginal delivery at 37 weeks, by inducing labour

(preferably with a Foley catheter bulb). Monitor both twins continuously with
CTG during labour. Do an elective caesarean section at 37 weeks if the first
twin is breech or transverse, or if there are obstetric indications, e.g. previous
caesarean section

 For monochorionic twins, plan an elective caesarean section (to prevent

intrapartum acute twin-to-twin transfusion) at 36 weeks. With onset of labour
at <36 weeks, consider allowing vaginal delivery, but monitor both twins with
continous CTG

 For triplets, plan an elective caesarean section at 33 weeks, after giving

betamethasone to accelerate fetal lung maturity

Notes on labour in twin pregnancy

 Treat preterm labour as for singleton pregnancies. Monitor maternal condition

in a high care area. Beware of pulmonary oedema if salbutamol and
betamethasone are used together
 Plot labour progress on a partogram
 Monitor both fetuses continuously using twin CTG if available
 Epidural analgesia is preferred
 Oxytocin may be used for induction and augmentation of labour

Delivery of the second twin, and management of the third stage

1. Immediately after delivery of the first twin, assess lie and presentation
2. Monitor fetal heart rate with continuous CTG
3. If cephalic or breech, allow descent, then rupture membranes and deliver
4. If transverse, attempt external version to breech or cephalic presentation,
using salbutamol 250 mcg IV over 2 minutes, if necessary to relax the uterus
5. Consider internal version to breech of persistent transverse lie by an
experienced registrar or consultant (easiest under epidural anaesthesia)
6. If contractions are inadequate, start oxytocin augmentation
7. For fetal distress, perform breech extraction or assisted vaginal delivery
8. Do an emergency caesarean section for the second twin if there is excessive
delay and assisted delivery or version are not feasible or unsuccessful
9. After routine management of the third stage of labour, add 40 units of
oxytocin to 1L Ringer-Lactate and infuse at 125 mL/hour to prevent PPH
 86

First twin delivered Assess lie and presentation

Monitor with CTG

Breech Transverse Cephalic

Await descent then External version, or Await descent then

rupture membranes internal version to rupture membranes
breech

Plan for assisted Plan for normal

breech delivery Failure vertex delivery
Consider oxytocin Consider oxytocin

Emergency
Fetal distress or caesarean section Fetal distress or
excessive delay excessive delay

Breech extraction Not feasible Vacuum or forceps

DELIVERY OF THE
SECOND TWIN
 87

BREECH PRESENTATION AND TRANSVERSE LIE

Local clinics may refer women with suspected breech presentation and trans-
verse lie to hospital for confirmation and further management. Ultrasound scan
must be done to confirm the presentation, assess liquor volume, and to exclude
multiple pregnancy, placenta praevia, uterine abnormality and fetal abnormality.

EXTERNAL CEPHALIC VERSION

External cephalic version (ECV) should be attempted on all women with singleton
breech presentations from 36 weeks gestation, with the following precautions:

1. Exclude possible contraindications – hypertension, scarred uterus, oligo-

hydramnios, antepartum haemorrhage, ruptured membranes, HIV infection,
uterine abnormalities
2. Give anti-D 100 mcg IM to Rhesus-negative women with no antibodies
3. Do not anaesthetise or sedate the woman
4. Use salbutamol 250 mcg IV to relax the uterus
5. Never use excessive force
6. Do a CTG tracing before and after ECV, whether successful or not
7. Observe the woman for a few hours for complications – labour, rupture of
membranes, antepartum haemorrhage, fetal distress

LABOUR AND DELIVERY

Elective caesarean section is the safest method of delivery for a baby with
breech presentation. Women with breech presentation at 38 weeks should be
admitted to hospital for elective caesarean section. Re-examine the woman
carefully before surgery to confirm that the presentation is still breech.

Admission of a woman with breech presentation in labour

1. Exclude fetal abnormality or multiple pregnancy, by ultrasound if necessary

2. Attempt ECV if there are no contraindications
3. Estimate fetal weight, maternal height and pelvic adequacy
4. Determine cervical dilatation and station of presenting part
5. Perform caesarean section unless suitable for vaginal delivery (below)

Vaginal breech delivery

Some women may prefer vaginal breech delivery, and some may arrive at
hospital in advanced labour. Vaginal breech delivery can be planned for these
women provided that all circumstances are favourable. Primigravidas should be
strongly advised to have elective caesarean section. Vaginal breech delivery
must be personally supervised by the most senior clinician available in the labour
ward.
 88

Breech presentation suitable for vaginal delivery

 The pregnant woman understands and accepts vaginal delivery

 Clinician experienced and confident with vaginal breech delivery
 No signs of pelvic contraction
 Maternal height >1.5 m
 Estimated fetal weight 1.5-3.5 kg
 Ultrasound excludes head extension (‘stargazing breech’)
 Frank or complete breech
 At 6 cm dilatation or more, the fetal buttocks should be at least at the level of
the ischial spines, and at full dilatation, should be at the perineum
 Labour progress 1 cm per hour
 Epidural anaesthesia is strongly advised

A dead or grossly abnormal fetus, or with estimated weight <800 g should be

delivered vaginally

Vaginal breech delivery technique

1. Get help and put the woman in lithotomy position. Call a paediatric doctor.
2. Cut an episiotomy after infiltration of the perineum with lidocaine 1%
3. Allow the breech to deliver itself and only assist in keeping the fetal back
facing upwards. Do not at any stage pull the baby down.
4. If extended knees prevent easy delivery, assist by flexing at the knees and
gently delivering each leg (Pinard manoeuvre)
5. After delivery of the trunk, allow the breech to hang, pull the cord down and
cover the delivered parts with a cloth
6. As the scapulae appear, be ready to assist with delivery of the arms
7. Deliver the arms if necessary (anterior or posterior), by running the fingers
from the fetal back over the shoulder and sweeping the arms down in front of
the chest, and then out
8. With difficult in delivering the arms, the posterior arm can be brought anterior
by rotating the baby, holding it by the hips and sacrum (Lovset manoeuvre)
9. Allow the baby to hang, and wait for the hairline to appear
10. Deliver the head by lying the baby over the right forearm (if right-handed) and
inserting the right middle finger into the baby’s mouth, with the index and ring
fingers supporting the cheek (Mauriceau-Smellie-Veit manoeuvre)
11. The left hand exerts suprapubic pressure downwards to flex the head
12. If the head does not deliver, keep the above manoeuvre and push the head
up a little and rotate laterally about 30 degrees, then attempt delivery as
before with an assistant providing firm suprapubic pressure
13. Consider symphysiotomy if the head still does not deliver, if possible
14. Should the fetal back face downwards after delivery of the arms, the head
may be trapped. Hold the feet and try to swing the baby anteriorly over the
maternal abdomen to flex the head, while grasping the shoulders with two
fingers of the other hand (modified Prague manoeuvre)
 89

TRANSVERSE LIE

External version may be attempted from 37 weeks’ gestation. Caesarean section

is required if version fails to achieve a stable longitudinal lie. Any woman
presenting in labour with a transverse lie (alive or dead, expected weight ≥1 kg)
needs delivery by caesarean section. Consider classical or low vertical uterine
incision, especially with dorso-anterior and dorso-inferior transverse lie.

PRETERM LABOUR

This is defined as labour at <37 weeks. Management depends on the gestational

age and/or estimated fetal weight. Most morbidity and mortality is related to
delivery before 34 weeks. Ultrasound helps to assess fetal weight and normality.

Always consider and exclude underlying maternal illness, especially HIV

related pneumonia, in women presenting with spontaneous preterm labour

Gestational age 34 weeks or estimated fetal weight 2 kg:

1. Exclude & treat specific causes of preterm labour, e.g. chorioamnionitis or

other infections (with fever and tachycardia), and abruptio placentae
2. Admit to labour ward
3. Manage labour as for term pregnancy

Gestational age 26-33+ weeks or estimated fetal weight 800 g – 1999 g:

1. Admit to a high care area

2. Give betamethasone 12 mg IM 12 hourly for 2 doses
3. Run a CTG tracing
4. With evidence of pre-eclampsia, abruptio placentae or chorioamnionitis, allow
labour to proceed with continuous CTG, or consider caesarean section
5. If the cervix is 6 cm dilated, allow labour to proceed
6. If the cervix is <6 cm dilated, give nifedipine tocolysis regimen or
indomethacin (below). Consider precautions and contraindications
7. Intravenous atosiban may be available for certain patients (e.g. cardiac
disease, multiple pregnancy), with consultant motivation
8. If nifedipine fails to stop contractions, consider adding indomethacin (at <32
weeks)
9. Deliver the baby slowly and gently, with an episiotomy if the perineum is tight

Gestational age 24+ weeks or estimated fetal weight 600+ g:

1. Admit to labour ward

2. Allow labour to proceed
3. Give betamethasone 12 mg IM 12 hourly for 2 doses
 90

4. If the baby is born alive, transfer to the nursery for resuscitation

Gestational age ≤24 weeks, or estimated fetal weight ≤600 g:

1. Manage as an inevitable miscarriage

2. Counsel the woman appropriately

NIFEDIPINE TOCOLYSIS REGIMEN

1. Insert a drip with Ringer-Lactate, and run 200 mL fast followed by 125
mL/hour

2. Give nifedipine 20 mg orally, then 10 mg orally after 30 minutes if painful

contractions persist. Follow with 10 mg orally every 6 hours if there are painful
contractions, up to a maximum of 48 hours. Then allow labour to proceed, or
discharge the woman if she is not in labour

Precautions
 Give oral nifedipine only in a high care area under close supervision
 Do not give nifedipine to women with cardiac disease, hypertension,
hyperthyroidism, or uncontrolled diabetes mellitus. Indomethacin may be
used in these women
 Do not give nifedipine to women with a heart rate 120/minute
 Observe the heart rate ½ hourly, or connect to a cardiac monitor
 Measure the BP hourly

INDOMETHACIN REGIMEN

Give indomethacin 50 mg stat, then 25 mg orally 4 hourly for a maximum

duration of 48 hours

Do not give indomethacin to women with renal dysfunction, asthma, or a history

of peptic ulceration

Do not give indomethacin at ≥32 weeks

 91

Preterm labour

Gestation Gestation Gestation

34 weeks, 26-33+ weeks, ≤24 weeks,
Fetus 2000 g Fetus Fetus ≤600 g
800-1999 g
2 kg
Allow labour to Betamethasone
proceed Allow labour to
proceed

Cervix 6 cm Cervix <6 cm, and

Pre-eclampsia no pre-eclampsia,
Abruptio placentae no abruption,
Chorioamnionitis no chorioamnionitis
No fetal distress

Antibiotics Tocolysis
Betamethasone
Allow labour to Betamethasone
proceed, consider Nifedipine and/or
caesarean section indomethacin

MANAGEMENT OF
PRETERM LABOUR
 92

PRELABOUR RUPTURE OF THE MEMBRANES

This is rupture of the membranes before the onset of labour. The diagnosis must
be confirmed by visual inspection, speculum examination, pH testing of vaginal
fluid or, if necessary, by liquor volume assessment on ultrasound. Management
depends on gestational age and/or estimated fetal weight (by palpation or
ultrasound).

Gestational age 34 weeks or estimated fetal weight 2 kg:

1. Give ampicillin 2 g IV stat then 1 g IV 4 hourly and metronidazole 400 mg

orally 8 hourly
2. If in labour, allow labour to proceed
3. If the woman is not in labour within 12-24 hours, induce labour with oxytocin
or oral misoprostol, pending her Bishop score (page 95)

Gestational age 26-33+ weeks or estimated fetal weight 800 g – 1999 g:

1. Admit to hospital
2. Do not do digital vaginal examination if not in labour, as this may introduce
pathogenic bacteria and cause chorioamnionitis
3. Give azithromycin 500 mg orally daily (or amoxicillin 500 mg 8 hourly)
AND
metronidazole 400 mg orally 8 hourly for 5 days
4. Give betamethasone 12 mg IM 12 hourly for 2 doses
5. Do not tocolyse if labour starts, irrespective of doses of betamethasone given
6. Observe temperature, heart rate, fetal heart rate, and pad checks 4 hourly
7. Palpate daily for evidence of chorio-amnionitis (irritable or tender uterus)
8. Do not measure white cell count or CRP (not sensitive or specific)
9. Do CTG daily
10. Induce labour at 34 weeks or at ≥2 kg, or if there are signs of chorioamnionitis
11. During labour, give ampicillin 2 g IV stat, then 1 g IV 4 hourly

Gestational age ≤24 weeks or estimated fetal weight ≤600 g:

1. Ensure that the membranes have definitely ruptured (reduced liquor volume
on ultrasound). If in doubt, admit to hospital to observe for liquor drainage

2. If rupture of membranes has been confirmed (inevitable miscarriage), induce

labour with oxytocin 10-20 units in 1 L Ringer-lactate at 120 mL/hr, after full
discussion of the problem with the woman

3. In exceptional cases, e.g. poor obstetric history, pregnancy prolongation may

be attempted in hospital under consultant supervision
 93

Prelabour rupture of the

membranes

Gestation Gestation Gestation

34 weeks, 26-33+ weeks, ≤24 weeks,
Fetus 2000 g Fetus Fetus ≤600 g
800–1999 g
2 kg
IV antibiotics Antibiotics
Induce labour Induce labour
after 12-24 hr after
counselling

Evidence of No evidence of
chorioamnionitis chorioamnionitis

IV antibiotics Conservative management

Betamethasone
Monitor fetus Oral antibiotics
Induce labour Betamethasone
Monitor for signs of infection
Induce labour at 34 weeks
IV antibiotics in labour

MANAGEMENT OF
PRELABOUR
RUPTURE OF THE
MEMBRANES
 94

CHORIO-AMNIONITIS

This is usually associated with prelabour rupture of membranes and preterm

labour, or with antepartum haemorrhage, but may occur in the absence of any
specific symptoms or signs. Both the woman and her baby are at significant risk
of severe infection. It is often difficult to make a diagnosis

Clinical signs of chorio-amnionitis include:

 Pyrexia 37.5 degrees

 Maternal heart rate 100/minute
 Uterine tenderness and/or irritability
 Fetal heart rate 160/minute
 Offensive liquor or meconium stained liquor

Management

1. If there is uncertainty about the diagnosis, exclude other causes of the

presenting symptoms and signs, and admit to the antenatal ward for
observation and fetal monitoring.
2. Give ampicillin 2 g IV 6 hourly, with metronidazole 400 mg orally 8 hourly
3. At gestation <34 weeks, give betamethasone 12 mg IM 12 hourly for 2 doses
4. Induce labour if the cervix is favourable, otherwise perform caesarean section
5. During labour, monitor the fetus with CTG
6. Continue ampicillin and metronidazole for 5 days after delivery

SUSPECTED PROLONGED PREGNANCY

This is pregnancy exceeding 41-42 weeks. There is a risk of intrauterine death,

intrapartum hypoxia and meconium aspiration. Suspected prolonged pregnancies
are referred to hospital from local clinics. Management is as follows:

1. Ensure that the gestational age has been correctly calculated

2. A report from an early ultrasound scan (24 weeks) should provide
convincing evidence of correct gestational age
3. If gestation ≥41 weeks, induce labour if no contraindications
4. If gestation <41 weeks, ‘stretch and sweep’ the cervix and discharge home
5. With uncertainty about gestation (menstrual dates or late ultrasound only):
- Ask about fetal movements, assess the cervix and do ‘stretch and sweep’,
and, if necessary, estimate liquor volume on ultrasound
- Induce labour if there are reduced fetal movements, a favourable cervix,
or reduced amniotic fluid index (<5 cm) or single deepest pool <2 cm.
- Do not induce labour if fetal movements and liquor volume are normal,
and the cervix is unfavourable for induction. Follow up in one week
6. During labour, monitor the fetus continuously with CTG
 95

INDUCTION OF LABOUR WITH A LIVE BABY

Frequent indications for induction of labour with a live baby include prolonged
pregnancy, hypertension and prelabour rupture of membranes. Contraindications
are placenta praevia, breech, transverse lie, fetal distress, previous caesarean
section and parity ≥5: elective delivery for these must be by caesarean section.

CERVICAL ASSESSMENT
Prior to induction of labour, the cervix needs to be assessed for favourability.
Use the Bishop score – a total ≥7 suggests that induction with amniotomy
followed by oxytocin is likely to be successful

Bishop score

Points: 0 1 2 3

Cervical dilatation <1 1-2 2-4 >4

(cm)
Cervical length >4 2-4 1-2 <1
(cm)
Station -3 -2 -1 ≥0

Cervical consistency Firm Average Soft

Cervical position Posterior Mid-position Anterior

If the cervix is favourable for induction (Bishop score ≥7):

1. Admit the woman to labour ward

2. Ensure fetal well-being by NST
3. Perform artificial rupture of membranes
4. Start oxytocin infusion 2 hours later
5. Monitor the fetus with continuous CTG

If the cervix is not favourable for induction (Bishop score <7):

1. Admit the woman to the antenatal ward

2. Ensure fetal well being by NST
3. Start oral misoprostol with/without Foley catheter bulb induction
4. If the cervix is not favourable after 24 hours, give prostaglandin E2 1 mg into
the posterior vaginal fornix every 6 hours, for 24 hours
5. Failed induction after 48 hours may necessitate caesarean section or further
expectant management
 96

Preparation of the cervix with a Foley catheter bulb

This is a good non-pharmacological and safe alternative to oral misoprostol or

vaginal prostaglandin E2, particularly for women with previous CS or parity ≥5

1. Pass a 30 mL bulb Foley catheter through the internal cervical os and inflate
the bulb to 50 mL
2. Put the bulb on traction by sticking the catheter to the inner thigh
3. Check for expulsion of the bulb every 12 hours
4. If the bulb won’t expel, consider infusing extra-amniotic saline at 50 mL/hour,
for a maximum 24-36 hours (in labour ward)
5. When the bulb is expelled, the cervix is favourable for amniotomy

Induction of labour with oral misoprostol

1. Presentation must be cephalic

2. Parity must be 4 or less
3. The cervix must be assessed as unfavourable for induction
4. There must be no history of previous caesarean section or uterine surgery
5. Make up the misoprostol solution as follows: Dissolve 1 tablet of misoprostol
200 mcg in 200 mL tap water in a clean brown plastic bottle (1 mcg/mL).
Shake well before each dose is given. Discard any unused solution after 12
hours
6. Give oral misoprostol 2-hourly for up to 24 hours or until labour starts:
- Dose: 20 mL (20 mcg) 2 hourly x 12 doses
7. Before each oral dosage, check for contractions. If there are ≥3 painful con-
tractions in 10 minutes, or maternal distress, assess the cervix and do a CTG
8. If the cervix is 3 cm dilated, transfer the woman to labour ward
9. If the cervix is <3 cm dilated, continue oral misoprostol 2-hourly and repeat
the cervical assessment in 2-4 hours
10. Do not give oxytocin <6 hours after the last dose of oral misoprostol
11. If the cervix is not favourable after 24 hours, stop misoprostol and consider
repeat misoprostol dosage, Foley catheter bulb induction, or other methods
12. If tachysystole (6 contractions in 10 minutes for at least 20 minutes) or
hypertonus (contraction lasting for 2 minutes) occurs:
a. Place the woman in a left lateral position
b. Perform a CTG tracing
c. Do not rupture membranes
13. If there is evidence of fetal distress on CTG:
a. Place the woman in a left lateral position
b. Give salbutamol 250 mcg IV over 2 minutes
c. Consider emergency caesarean section if there is no improvement
14. When the woman is in labour, monitor the fetus with continuous CTG
 97

Medical supervision of labour induction

The woman must be assessed by a doctor at least twice each day in the
antenatal ward (morning and evening) during misoprostol or bulb induction

Labour indicated
Parity 4 or less
Cephalic presentation
No previous caesarean
section

Add 200 mcg misoprostol to 200 mL

water: give 20 mL 2-hrly orally for 12
doses or until labour starts

Before each dose of oral

misoprostol, check for
uterine contractions

Less than 3 painful 3 or more painful

contractions in 10 contractions in 10
minutes, and no minutes, or distressed
distress

Assess the cervix,

perform CTG

Continue with oral Cervix <3 cm Cervix 3 cm

misoprostol dilated dilated

ORAL Insert a drip and

MISOPROSTOL transfer the
woman to labour
FOR INDUCTION ward

OF LABOUR
 98

RHESUS INCOMPATIBILITY

Rapid rhesus (D) blood group testing is done on all pregnant women at the first
antenatal visit, or at delivery in unbooked women. Rhesus-positive women need
no further specific management.

If a woman is pregnant and Rhesus-negative, send blood for atypical

antibody testing at 26, 32 and 36 weeks:

 If antibodies are found, refer the woman to the Fetal Medicine Unit for further
management (fetal middle cerebral artery Doppler, cordocentesis and
transfusion if necessary, elective delivery as advised by the Fetal Medicine
Unit)

 If no antibodies are found, give prophylactic anti-D 100 mcg IM as follows:

- If amniocentesis or external cephalic version is performed

- If there is antepartum haemorrhage
- If the woman suffers any abdominal trauma
- After delivery to all Rhesus-negative mothers, if the baby is Rhesus-
positive or its Rhesus status is unknown
- Following termination of pregnancy (TOP), miscarriage before 20 weeks,
or ectopic pregnancy, give anti-D 50 mcg IM

PREVIOUS CAESAREAN SECTION

Women with previous lower segment caesarean sections should have antenatal
care at their local clinics, but should be seen at least once by a doctor at a
hospital antenatal clinic. Here a delivery plan can be discussed with the woman
and the gestational age can be confirmed, if necessary, by an ultrasound scan.
Women with a previous caesarean section are at increased risk of uterine rupture
during labour. Labour and delivery must be conducted in hospital

Indications for elective repeat caesarean section

 A previous vertical uterine incision (classical and low vertical operations)

 Previous uterine rupture
 Two or more previous caesarean sections
 Previous pelvic floor or incontinence repair
 High risk of disproportion, e.g. big baby, maternal short stature
 Where the woman requests an elective caesarean section
 Co-existing obstetric problem, e.g. multiple pregnancy, breech presentation
 99

MANAGEMENT OF “TRIAL OF LABOUR” (VBAC)

This is similar to normal labour with the following precautions:

 Run an intravenous drip with Ringer-Lactate solution at 120 mL/hour

 Give only clear fluids orally
 Insert a urinary catheter
 Monitor labour with continuous CTG
 Do 2 hourly cervical assessments
 Do not augment labour with oxytocin
 Strict adherence to correct partogram use
 Observe carefully for evidence of uterine rupture:

- Fetal tachycardia, decelerations or death

- Vaginal bleeding
- Haematuria
- Abdominal pain between contractions
- Sudden cessation of contractions
- Suggestive findings on abdominal palpation (tenderness, fetal extrusion)
- Presenting part not palpable or abnormally high on vaginal examination

Emergency caesarean section is recommended if:

 The membranes have ruptured and the woman is not in labour

 The latent phase of labour exceeds 8 hours
 Progress in the active phase of labour crosses to the right of the alert line
(cervical dilatation rate <1 cm/hour)
 There is evidence of uterine rupture (above)

POSTPARTUM OBSERVATIONS

Observe the woman closely during the fourth stage of labour, as the uterus may
rupture during delivery, with intra-abdominal, retroperitoneal, and/or vaginal
bleeding. Routine palpation of the old uterine scar is not necessary. Signs of
possible rupture, include:

 Rising heart rate

 A drop in BP
 Lower abdominal pain
 Severe lower abdominal tenderness
 Postpartum haemorrhage
 Haematuria

If uterine rupture is suspected, arrange laparotomy to repair the uterus. Inform

the woman during the consent procedure that hysterectomy may be necessary.
 100

POOR OBSTETRIC HISTORY

Thorough history taking is essential. A special clinic should provide expert

management of women with recurrent problems in previous pregnancies.

PREVIOUS UNEXPLAINED STILLBIRTH IN THE THIRD TRIMESTER

 Advise against smoking/alcohol/illicit drugs

 Refer to the dietician for a healthy eating plan if BMI>30 at booking
 Do a dating ultrasound scan at the first contact with the patient, then book a
1st trimester scan (11-14w) or if further along an anomaly scan at 18-23
weeks
 Pull booking bloods and TSH
 Take blood for APS:
- Anticardiolipin antibodies - ACLA
- Anti-Beta 2 glycoprotein 1 antibody – anti-B2GP1
- Lupus anticoagulant – LA (take sample from an uncuffed arm)
- Antinuclear antibodies - ANA
 Consider thrombotic screen, including Factor V Leiden, Protein C and Protein
S for APS-negative patients (specialist clinic only) – best done outside of
pregnancy
 Ask the woman to count fetal movements from 28 weeks (10 in 2 hours)
 Screen for gestational diabetes from 24 weeks with a 75g OGTT
 Book an ultrasound and umbilical artery Doppler at 26 weeks and 32 weeks
 Review the woman weekly from 36 weeks
 Deliver at 38-39 weeks

Antiphospholipid Syndrome (APS)

The diagnosis of APS requires at least 1 of the clinical criteria and 1 of the
laboratory criteria. Laboratory criteria must be positive on 2 or more occasions, at
least 12 weeks apart. Due to the fact that the window of opportunity to help
prevent further damage to the placenta is small, the patient is started on
treatment based on one set of bloods. Thus she should be retested 12 weeks
after delivery and if still positive, be referred to medicine.
Clinical criteria
 1 or more unexplained deaths of morphologically normal fetuses at or
beyond the 10th week of gestation, with normal fetal morphology
documented by ultrasound or by direct examination of the fetus
 1 or more premature births of morphologically normal neonates before the
34th week of gestation because of eclampsia or severe pre-eclampsia
 3 or more unexplained consecutive spontaneous miscarriges before the
10th week of gestation
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Laboratory criteria – at least one must be positive

 Lupus anticoagulant (LA)

 Anticardiolipin antibody (ACLA)
 Anti-Beta 2 glycoprotein 1 antibody (anti-B2GP1)
APS is treated with enoxaparin 0.5 mg/kg SC 12 hourly and aspirin 75 mg daily
given from 6 weeks gestation up to term.

PREVIOUS SECOND TRIMESTER MISCARRIAGE

 Take a careful history of the miscarriage/s:

In addition to the above points on history
- Evidence of cervical weakness – rapid painless delivery of a live fetus
after membrane rupture or delivered with intact membranes. Note that a
very premature fetus may die during the delivery process so
documentation of fetal heart activity is important prior to delivery.
- Was a baby seen, and was it alive at delivery?
 On vaginal examination, feel for dilatation and length of the cervix
 Do a dating ultrasound scan at the first antenatal visit. Arrange a 1st trimester
scan including cervical length. If already past 14 weeks, arrange a cervical
length scan as soon as possible. This may be repeated after 2 to 4 weeks to
look for shortening, or at the 18-23 weeks scan.
 Decide on the need for cervical cerclage, and type of cerclage.

INDICATIONS FOR CERVICAL CERCLAGE

 A history strongly suggestive of cervical weakness

 Prior cervical cerclage for cervical weakness
 Three consecutive second trimester miscarriages (unless fetuses born dead)
 Short cervix on transvaginal ultrasound scan (<2.5 cm), or open cervix felt, in
a woman with a history of 2nd trimester loss or previous preterm labour (<34w)
 Significant cervical shortening over 4 weeks on serial ultrasound scans
 Uterine anomalies (senior to decide)

Cervical cerclage is usually performed at 14 weeks, but may be done up to 24

weeks. ‘Rescue’ cerclage may be done in selected cases at 25-26 weeks

TWO OR MORE PREVIOUS UNEXPLAINED FETAL DEATHS

 The main concern is antiphospholipid syndrome (APS) or thrombophilia

 Using a plain (red-topped) tube, take blood for APS:
- Antinuclear antibodies
- Anticardiolipin antibodies – IgG, IgM, IgA
 102

- Anti-Beta 2 glycoprotein1 antibody

 Consider thrombotic screen, including Factor V Leiden, Protein C and Protein

S for APS-negative patients (specialist clinic only)

WHEN TO TEST FOR ANTIPHOSPHOLIPID SYNDROME

 Two or more unexplained fetal deaths

 Previous fetal death associated with early onset pre-eclampsia
 Recurrent fetal growth restriction with or without hypertension
 One unexplained fetal death and a history of thromboembolism

PREVIOUS PRETERM DELIVERY

This refers to the delivery of a preterm baby that died or required special care, in
the previous pregnancy

 Obtain a good history of the preterm birth

 Do an ultrasound scan at the first antenatal visit, including estimation of
cervical length on transvaginal scan
 Before 24 weeks, feel for dilatation of the cervix on vaginal examination
 Look for evidence of bacterial vaginosis or trichomoniasis and treat
appropriately (metronidazole 2 g orally as a single dose)
 Consider giving progesterone vaginal pessaries 200 mg daily for women with
recurrent preterm delivery (consultant/special clinic decision)
 Consider cervical cerclage based on cervical length findings
(consultant/special clinic decision)
 Consider prophylactic corticosteroids (betamethasone 12 mg IMI and
repeated after 12 hours) at ≥26 weeks
 From 34 weeks, no further specific management is needed and the woman
can continue antenatal care and plan for delivery at her local clinic
 103

Chapter 5 Fetal medicine

THE FETAL MEDICINE UNIT

The discipline of Fetal Medicine has seen major recent advances, with improved
imaging technology, advances in biochemical testing, and expanding knowledge
and expertise. Prevention, prophylaxis, diagnosis and treatment are now
available for many conditions that would otherwise have a disastrous outcome.

In addition to providing ultrasound referral, the Fetal Medicine Unit offers:

 First-trimester screening for aneuploidy (nuchal translucency and fetal

anatomy)
 Chorion villus sampling (CVS), amniocentesis and cordocentesis, with first
results available within 72 hours
 Pre-eclampsia screening using uterine artery Doppler studies
 Screening for preterm labour by measuring cervical length
 Fetal procedures such as intrauterine blood transfusion

THE ULTRASOUND SCAN AT 11-14 WEEKS

Ideally, all pregnant women should have their first scan between 11 and 14
weeks. Early assessment of mother and fetus result in fewer antenatal visits, less
invasive procedures, and better detection rate of congenital abnormalities.
The purpose of the first trimester scan is:

1. To date the pregnancy accurately

Crown-rump length measurement allows accurate calculation of the gestational
age

2. To diagnose major fetal anomalies

In about 1% of pregnancies major abnormalities may be visible at this scan.
These abnormalities may be incompatible with life or may be correctable

3. To calculate the risk for chromosomal abnormalities

All women, of whatever age, have a chance of delivering a baby with chromo-
somal abnormalities, e.g. Down’s syndrome. The risk of a chromosomal
abnormality is calculated from the maternal age (MA), gestational age, fetal
nuchal translucency (NT), and presence or absence of the nasal bone (NB).
Assessment of (MA + NT + NB) gives a detection rate of 92%. With the addition
of serum PAPP-A (pregnancy-associated placental protein A), free beta-hCG and
Placental Growth Factor (PIGF), the detection rate improves to around 97%.
Women with increased nuchal translucency or increased overall risk may be
offered CVS or amniocentesis after counseling.
 104

4. To determine the risk for pre-eclampsia

Increased resistance in the uterine arteries detected by Doppler velocimetry
suggests an increased risk for development of pre-eclampsia. A reduced PAPP-
A & PIGF serum level are good markers for pre-eclampsia prediction

5. To determine the risk for preterm labour

The measurement of the cervical length in the first trimester enables the
calculation of a risk of preterm labour before 34 weeks

6. To diagnose multiple pregnancy

Approximately 2% of natural conceptions and 10% of assisted conceptions result
in multiple pregnancies. The scan helps determine chorionicity in twins

7. To diagnose early pregnancy failure

Early pregnancy failure (missed abortion) can be identified in about 3% of
women.

THE ULTRASOUND SCAN AT 18-23 WEEKS

Irrespective of the outcome of the 11-14 week scan, another scan at 18-23
weeks is recommended to identify structural abnormalities. This is particularly
important in fetuses with increased nuchal translucency with normal karyotype at
11-14 weeks, because of the higher risk of cardiac abnormalities and genetic
syndromes. In addition, the assessment of the feto-maternal circulation and the
cervical length continue to provide important information.

Down’s syndrome detection and screening from 15 to 23 weeks

1. Biochemistry screening

Maternal serum levels of intact hCG, unconjugated estriol, and alphafeto-protein

(triple test) may be measured to compute a Down’s syndrome risk at 16-18
weeks. Women with ‘positive’ tests are counseled for possible amniocentesis.
Biochemistry screening currently not available in public hospitals.

2. Ultrasound detection of soft markers

A soft marker is structural anomaly visible on ultrasound scan rarely of postnatal

significance but associated with a chromosomal abnormality. The presence of
one or more of the following may suggest the possibility of Down’s syndrome,
and therefore counseling for amniocentesis:

 Cardiac abnormalities
 Renal pyelectasis
 Short femur and/or short humerus, Sandal gap
 Hypoplasia of the middle phalanx of the fifth finger and clinodactyly,
 105

 Nuchal fold thickening

 Absent or hypoplastic nasal bone

3. Structural abnormalities (hard markers)

Hard markers are serious structural abnormalities frequently associated with

Down’s syndrome and other chromosomal abnormalities, indicating a need for
fetal karyotyping by amniocentesis or cordocentesis. These include:

 Duodenal atresia
 Omphalocele
 Cystic hygroma
 Hydrothorax
 Atrial septal defect and/or ventricular septal defect of the heart
 Cerebral ventriculomegaly

The Non Invasive Prenatal Test (NIPT)

DNA isolated from maternal blood not only contains maternal DNA, but also a
small amount of fetal DNA: the fetal fraction of cell-free DNA in maternal blood
from 10 weeks onwards is about 10-15% of all cell-free DNA.
It is possible to analyze this cell-free DNA to detect fetal trisomies such as Down
syndrome.
The NIPT test is a very accurate screening test for Trisomy 21, 18, 13 and sex
chromosomal abnormalities with an accuracy of >99%. Patients who screen
positive for a chromosomal abnormality with the NIPT still need to have an
invasive test for confirmation of the chromosomal abnormality (a diagnostic test).
In addition to the above chromosomal abnormalities, a number of common
microdeleltions such as Di George, Prader Willi, Angelman Synrome, Cri du
Chat, can be tested as well. NIPT is only available in the private sector.

WOMEN FOR REFERRAL TO THE FETAL MEDICINE UNIT

The table below shows categories of women who may be referred to the Fetal
Medicine Unit for genetic counseling, detailed scanning, and invasive tests if
required. Refer women as early as possible in the pregnancy, to allow time for
counseling and decisions, and for early diagnosis of any disorders. CVS is best
done at 11-14 weeks and amniocentesis at 15-23 weeks.
 106

Risk factors for genetic disorders and birth defects

Women at risk Invasive tests

Advanced maternal age (40 years) CVS

Amniocentesis
Three or more first trimester miscarriages Parental blood
Amniocentesis
Previous child with a genetic disorder/birth defect, or family CVS
members affected by a specific genetic disorder. Amniocentesis
Cordocentesis
Exposure to teratogen drugs or toxins during pregnancy,
e.g. warfarin, retinoids, alcohol, antiepileptic drugs, lithium
Maternal infection during pregnancy Maternal blood
Cordocentesis
Maternal illness e.g. pregestational diabetes mellitus,
congenital heart conditions, thyroid disease
Couples in consanguineous relationships and women from Parental blood
ethnic groups at high risk for specific recessive disorders, CVS
e.g. Ashkenazy Jews (Tay-Sachs), Greeks and Cypriots Amniocentesis
(thalassaemia) and Central Africans (sickle cell disease)

POSTNATAL INVESTIGATIONS

Where a genetic condition or birth defect is suspected, the following steps should
be followed to obtain a diagnosis so that appropriate postnatal counseling may
be provided about risks of recurrence of the condition in a future pregnancy.

History and basic external examination

 Obtain a full pregnancy history, including possible exposure to teratogens

 Obtain a full family history
 Note whether there was oligohydramnios or polyhydramnios
 Record head circumference, weight, length, right foot length, and all abnormal
external clinical features
 With parental consent, take photographs to show all the clinical features

Special investigations

 Check or repeat syphilis serology (RPR)

 Do a full body x-ray (babygram)
 Send blood for karyotyping and other tests as clinically indicated
 107

Extended investigations (when necessary) for a stillborn baby

 Investigate as above (RPR, photographs, babygram)

 Consider Kleihauer test, Rh group and Coomb’s test, and diabetes screening
 For a fresh stillbirth, take heparinised blood from the heart and send for
karyotyping
 In addition, or alternatively, remove a piece of full-thickness skin from the
baby’s popliteal fossa, place it in sterile saline, and ensure it reaches the
laboratory within 48 hours for karyotyping
 If possible, request an autopsy for suspected cardiac and renal disorders, and
for congenital anomaly syndromes

PROCEDURE FOR PERINATAL AUTOPSY

1. Inform the mother or parents and nursing staff about plans for autopsy
2. Send aborted fetuses (<500 g) with their placentas to the laboratory in sterile
saline (not for autopsy)
3. Put a 3X3 cm piece of placenta in formalin and send it for histology. Indicate
on the slip that the baby is also being sent for autopsy. Send another piece of
placenta in sterile saline for MCS
4. Complete an autopsy consent form with the mother (if she agrees)
5. Complete separate hospital and laboratory autopsy request forms
7. Contact the pathology registrar on call to arrange any further details
8. Take all completed forms to the mortuary
9. Arrange a follow-up date ( 1 month) for the mother or parents

LIST OF SOME WELL KNOWN AND POSSIBLE TERATOGENS

Maternal infections Maternal medical conditions

Syphilis Diabetes mellitus
Toxoplasmosis Epilepsy
Rubella Hypo- and hyperthyroidism
Cytomegalovirus Systemic lupus erythematosus
Human parvovirus B19 Phenylketonuria
Herpes simplex virus

Drugs/chemicals/radiation
Recreational drugs: Ethyl alcohol, cocaine
Warfarin, Ergotamine, Lithium, Retinoids
Anticonvulsants: phenytoin, valproic acid
Antineoplastic drugs: methotrexate, cyclophosphamide, aminopterin
Antibiotics: tetracycline, kanamycin, streptomycin
X-ray radiation in large doses
Heavy metals: mercury, lead
 108

Chapter 6 Medical disorders

ANAEMIA AND TRANSFUSION

ANAEMIA

Anaemia in pregnancy is defined as a haemoglobin (Hb) level <11 mg/dL, but is

managed actively if Hb <10 g/dL. Most women with anaemia are iron deficient,
but some have infections (TB, urinary tract infection, HIV, malaria), and a few
have genetic disorders (e.g. sickle cell). Consider family and travel history.

Screening and prevention

 All pregnant women must have their Hb measured at the first antenatal visit,
and repeated at 32 and 36 weeks
 All pregnant women to receive ferrous sulphate 170 mg (or ferrous fumarate
200 mg) equivalent to 65 mg elemental iron, with folate 5 mg daily orally

Management of anaemia

1. If Hb <8 g/dL: Start full-dose haematinics – oral ferrous sulphate 200 mg with
vitamin C 100 mg, 3 times daily, with folic acid 5 mg daily. Take blood for
FBC, retics and morphology, and refer for investigation (Haematology Clinic)

2. If Hb is 8-9.9 g/dL: Management depends on gestational age:

a. Pregnancy 36 weeks: Take blood for FBC and refer to Haematology
Clinic. May need intravenous iron.
b. Pregnancy 30-35 weeks: Give full-dose haematinics. Recheck Hb in 2
weeks. Hb should improve by at least 1 g/dL. If inadequate improvement,
take blood for FBC, retics and morphology, and refer to Haematology
Clinic
c. Pregnancy <30 weeks: Give full-dose haematinics. Repeat Hb after 3
weeks: if Hb has not improved by 2 g/dL in 3 weeks, take blood for FBC,
reticulocyte indices and morphology, and refer to Haematology Clinic. If
Hb is improving, reassess after another 3 weeks

3. In addition to the above, look for and manage any underlying infection

4. Evaluate symptomatic anaemic patients carefully and consider referral to

Haematology Clinic or hospital admission
 109

Women who cannot tolerate iron tablets

Adjust the regimen by, e.g. omitting vitamin C, giving coated tablets, reducing the
dose, breaking tablets in half, giving small frequent doses, or children’s syrup.
Refer any anaemic woman who still cannot tolerate iron to Haematology Clinic.

Advice to anaemic pregnant women

 Encourage honesty about compliance or intolerance to medication

 Advise consumption of meat, particularly liver (iron) and fresh fruit (vitamin C)
 Discourage pica (consumption of ash, soil, clay, or other non-nutritive items)
 Inform that iron must not be taken at the same time as calcium or antacids
 Discourage excessive consumption of tea or coffee
 Warn about digestive side-effects with iron: advise taking iron during meals

OBSTETRIC HAEMATOLOGY CLINIC

Ideally, patients with haematological disorders in pregnancy should be managed

in a special clinic run jointly by an obstetrician and a haematologist.

Problems that should be referred

 Hb level decreasing on antiretroviral therapy and haematinics

 Anaemia as described above, and anaemia with an Hb <10 g/dL with a mean
cell volume (MCV) ≥100 fL
 Thrombocytopaenia other than that caused by pre-eclampsia or acute crises
 Current or previous leukaemia or lymphoma
 Patients who have recently received cancer chemotherapy
 Other pre-existing haematological disease

MANAGEMENT OF ANAEMIA

Iron deficiency anaemia

 A low MCV and a response to iron suggest iron deficiency

 Treatment is with haematinics at full dose (above)
 Treat any current infection
 Review at intervals according to gestational age, severity of anaemia, and
obstetric risk status (above)
 Do baseline FBC, differential count and morphology, then follow up with FBC
and reticulocyte parameters. Iron studies are not routinely done
 With good response, down-refer back to the woman’s local clinic
 Failure to respond to iron therapy requires further investigation and may
necessitate the use of intravenous iron
 Blood transfusion is only indicated for cardiac failure, or obstetric reasons.
 110

Megaloblastic anaemia

 This is more commonly seen in pregnant women from rural areas

 Diagnosis is made by finding a high MCV with megaloblastic changes on
peripheral blood smear
 Send blood for red cell folate and serum vitamin B12 levels
 Treatment is folic acid 5 mg orally daily and/or vitamin B12 1000 µg IM daily
for 5 days, then weekly for 4 weeks, then monthly
 Follow up with FBC and reticulocyte indices to assess response
 If response to treatment is satisfactory, refer back to local clinic or hospital
antenatal clinic, depending on obstetric risk status
 Failure to respond requires investigation with bone marrow aspiration and/or
trephine biopsy

LABOUR AND DELIVERY OF ANAEMIC PATIENTS

Measure Hb on admission, unless a very recent result (<2 weeks) is available

 If Hb 10 g/dL, no special measures need to be taken

 If Hb <8.0 g/dL, transfuse 1-2 units of blood if woman is scheduled for
emergency caesarean section
 If Hb <6.0 g/dL, transfuse 1-2 units of blood if vaginal delivery anticipated
 The amount of blood transfused depends not only on the Hb level, but on the
obstetric risk factors for haemorrhage. It should seldom be necessary to
transfuse more than 1 unit of blood for anaemic patients in labour

Postpartum care

 Use oral iron wherever possible to manage postpartum anaemia

 Transfusion is not indicated on the basis of an Hb result alone
 Should blood transfusion be considered, always start with only one unit of
blood and assess the symptomatic response
 Ensure patients with chronic haematological problems (e.g. immune
thrombocytopaenia or sickle-cell) are on appropriate treatment, and refer
them back to their clinic or doctor, with a letter
 On discharge, refer current patients of the obstetric Haematology Clinic back
to that clinic, with latest results, including pre-transfusion FBC, reticulocyte
indices, and red cell morphology.
 On discharge, refer other (uncomplicated) anaemic patients and those who
have been transfused to their local clinic for follow up of the anaemia
 Prescribe full-dose haematinics on discharge, with a plan to continue for 6
months
 111

RED CELL BLOOD TRANSFUSION

 Packed cells are normally used

 Transfuse just enough to reverse symptoms or reach a satisfactory level for
delivery or operation. One unit may be sufficient
 Reassess clinical findings and blood requirements before giving multiple
transfusions
 If multiple transfusions are anticipated, as in a case of confirmed bone
marrow aplasia, give only leucodepleted blood units

No patient with anaemia should be transfused without first doing FBC,

reticulocyte indices, red cell morphology and differential count. Patients with
uninvestigated anaemia requiring transfusion (not because of an acute bleed),
should in addition have blood taken for vitamin B12, red cell folate, and iron
studies before transfusion. Any question of marrow aplasia or abnormal
morphology must be referred to Haematology Clinic or haematologists.

If giving 2 or more units in normovolaemic patients, give 40 mg furosemide IV

with each unit of blood

Indications for blood transfusion in obstetrics

 Anaemia with cardiac failure

 Anaemia with bone marrow suppression (aplasia)
 Severe symptoms of anaemia - these can be confused with vasovagal
symptoms, or tiredness post partum
 Anaemia before caesarean section (Hb <8 g/dL)
 Anaemic women at high risk of haemorrhage e.g. with placenta praevia
 Acute severe haemorrhage
 Anaemic women who need to undergo an immediate general anaesthetic.
 Anaemia with severe sepsis
 Obtain specialist advice before transfusing patients with chronic haemolytic
anaemias e.g. sickle cell anaemia – they may need exchange transfusion

NB: Transfuse the patient and not the haemoglobin result.

 112

DIABETES MELLITUS

Obstetric diabetic clinic

Pregnant diabetic patients are best managed in a combined clinic run by an

obstetrician, internal medicine specialist, nurse and dietician. Refer all pregnant
diabetic women to this clinic as early as possible in the pregnancy.

PREGESTATIONAL DIABETES MELLITUS

This is diabetes that has been present before the current pregnancy. These
women require tight control of their blood glucose levels from the time of
conception, and should book for antenatal care as soon as pregnancy is
confirmed. Pregestational optimization of blood glucose control is the ideal.
Gestational diabetes (GDM) refers to diabetes diagnosed for the very first time
during the index pregnancy.

First assessment

 Initial admission is not always required if blood glucose control is good

 Take FBC, U&E; HbA1C (<6,5% = good, 7-10 = average, >10 = poor control)
 Take urine for albumin:creatinine ratio
 Order baseline ultrasound scan
 Do fundoscopy and refer women with proliferative retinopathy to an
ophthalmologist
 Convert all insulin dependent diabetics from Actraphane and other insulin
combinations to equivalent dosages in one of the following regimens:
 Three times daily short acting insulin and a night time dose of intermediate
acting insulin
 Alternatively, twice daily combined intermediate and short acting insulin
(Humulin N and R)
 Women with type 2 diabetes may be converted from oral hypoglycaemic
agents to Humulin N and R, or may remain on oral agents (eg metformin),
individualized at the diabetic clinic

Hospital admission for glucose control

 Prescribe a 30-35 kcal/kg/day diabetic diet, with 50% low GI carbohydrate,

30% fat and 20% protein, and 80 g/day of fibre
 Perform six-point profiles (fingerprick capillary glucose before, and 1 hour
after each meal of breakfast, lunch and supper)
 Using standard insulin regimen as described above, aim for:
o Fasting capillary glucose values <5.3 mmol/L
o 1-hour postprandial values <7.8 mmol/L
o 2-hour postprandial values <6.4 mmol/L
 113

 If on a twice daily regimen, add a midday dose if the total daily insulin
requirement exceeds 120 units/day, or if control is difficult during the day
 Teach the woman to measure her own blood glucose and inject herself with
insulin, and to understand recognition and treatment of hypoglycaemia.
 Discharge the woman once good control is achieved

Continuing antenatal care

 Outpatient 6-point blood glucose measurements are recorded daily by the

woman (½ hour before, 1 and 2 hours after breakfast, lunch and supper)
 Attendance is 2-weekly to 32 weeks, then weekly until admission at 37 weeks
 Perform ultrasound scans for growth or macrosomia at 28 and 34 weeks
 Do NST weekly from 32 weeks
 Admit to hospital at 37 weeks, with 6-point profiles and NST on alternate days

Labour and delivery

 Aim for induction of labour at 38 weeks if there are no complications

 Consider earlier induction with poor obstetric history, poor control, IUGR,
hypertension, fetal macrosomia, retinopathy, nephropathy, and neuropathy
 Preterm induction may require prophylactic betamethasone 12 mg IMI daily
for two doses, with a supplemental insulin sliding scale
 Caesarean section should be done for estimated fetal weight >4 kg
 Elective caesarean section should be done as early as possible in the day
 Standard methods of induction are used
 Give only the Humulin N dose on the morning of planned delivery
 Transfer to a high care area for induction when in labour, keep nil per os
 Measure hourly fingerprick capillary glucose levels during labour
 Run 5% dextrose-saline 1000 mL with 20 mmoL of KCL and 10 units of rapid
acting soluble insulin (Humulin R) at 100 mL/hour; and monitor capillary
glucose levels hourly. Insulin is given as follows:
o <4 mmol/L: no insulin
o 4-7 mmol/L: 10 units insulin in 1 L at 100 mL/hour (1 unit/hour)
o >7 mmol/L: 20 units insulin in 1 L at 100 mL/hour (2 units /hour)
 Give oxytocin, if needed, through a separate 200 mL infusion bag
 Monitor fetus with continuous CTG

Postpartum care

 After caesarean section, give 5% dextrose-saline with 20 mmoL of potassium

chloride – 3 L in the first 24 hours
 Measure 4 hourly fingerprick capillary glucose
 Give a 4 hourly sliding scale of SC Humulin R based on blood glucose level
 Note that insulin requirements drop sharply among women with GDM
 114

Blood glucose level (mmol/L) Humulin R dose (units) SC

6.0-9.9 0
10.0-11.9 2
12.0-13.9 4
14.0-15.9 6
16.0-17.9 8
≥18 10 and call doctor

 Re-introduce pre-pregnancy insulin or oral hypoglycaemic drugs cautiously as

appetite may be poor and insulin requirements may be low in the first few
days after delivery
 Discharge the woman to be followed up at her normal diabetic care provider,
with a discharge summary
 Breastfeeding mothers may need less insulin or an increased dietary intake
 For contraception, tubal ligation, progestin, low-dose combined
contraceptives and intrauterine devices are acceptable.

Diabetic ketoacidosis in pregnancy

Diagnosis

 Clinical features include polyuria, polydipsia, abdominal pain, weakness,

vomiting, hyperventilation, dehydration, tachycardia, hypotension,
disorientation, and coma
 Tests reveal blood glucose 17 mmol/L, glycosuria and ketonuria, arterial
blood pH <7.3, serum bicarbonate <15 mmol/L, base excess > -7, and raised
serum urea

General measures

 Admit the woman to a high care area and record all findings on an ICU chart
 Nurse in left lateral position
 Monitor fetal heart rate by CTG
 Insert a large bore (16G) intravenous cannula
 Take blood for glucose, ketones, FBC, U&E, culture, and ABG. Repeat
glucose and U&E hourly at first, and venous blood gas 2 hourly
 Insert a urinary catheter and monitor urine output hourly
 Send a catheter specimen of urine for MCS
 Use CVP and peripheral arterial lines only for severe acidosis or hypotension
 Search for predisposing factors and sites of infection
 Do not hesitate to consult internal medicine specialists for advice
 115

Specific measures

1. Fluids

 Give normal saline 1 L for the first half-hour, followed by normal saline over
one hour. For hyperosmolar nonketotic coma follow with half-normal saline
 Continue rehydration at 1 L/1-2 hours (6-12 L in 12-24 hours) depending on
clinical response. Add potassium (below). Aim for urine output of 1
mL/kg/hour, provided renal function is normal
 If sodium level rises to >150 mmol/L or when glucose falls to <15 mmol/L,
change to 5% dextrose water with potassium (below) at 150-300 mL/hour

2. Potassium

 Withhold potassium if ECG shows hyperkalaemia or potassium >5.5 mmol/L

 Once rehydration has commenced and urine output is satisfactory, replace
potassium. Never exceed 20 mmol potassium per hour IV.

Potassium level (mmol/L) Concentration (mmol/L IV fluid)

3.0 40
3.1-4.0 30
4.1-5.0 20
5.1-6.0 10
6.0 0

3. Phosphate

 Replace phosphate when supplementing potassium initially

 Infuse potassium phosphate 20 mmol/L IV over one hour

4. Insulin – use low dose Humulin R

 Delay giving insulin until potassium level is known to be >3.5 mmol/L

 Give 10 units IV followed by a continuous infusion at 5-10 units/hour, or
hourly boluses of 5-10 units IV
 If fall in blood glucose is <4 mmol/hour, double the insulin dose
 Change to SC sliding scale insulin if base excess > -7 mmol/L
 Once the patient is fully alert, commence twice daily SC insulin

4. Sodium bicarbonate

 Only give sodium bicarbonate if pH <7.0 and serum potassium >4.0 mmol/L
 Add 25-50 mL 8.5% solution to 200 mL water or 0.45% saline with 10 mmol
postassium and run in over one hour; can repeat until pH >7.0.
 116

GESTATIONAL DIABETES MELLITUS (GDM)

This is glucose intolerance that develops during pregnancy, or is noted for the
first time during the current pregnancy.

Screening and diagnosis

Screening is based on history taking at antenatal clinic and the presence of

glycosuria at clinic visits. Random blood glucose testing may be done if there is
strong suspicion of diabetes. A random level ≥11 mmol/L is diagnostic. An oral
glucose tolerance test (OGTT) is done in the presence of significant risk factors.

An OGTT is usually done from 24 weeks onwards. Blood glucose levels in

gestational diabetics may only become abnormal in the third trimester, so an
OGTT may delayed to 28 weeks for some women, or repeated at 28 weeks if an
earlier OGTT was negative.

Screening for GDM

o Glycosuria 1+ on two occasions, or 2+ on one occasion.

o Family history of diabetes
o Previous gestational diabetes
o Weight ≥100 kg or BMI > 40 kg/m2.
o Previous unexplained stillbirth.
o Previous macrosomic baby (weight > 4 000 g).
o Maternal age >40 years.
o Polycystic ovarian syndrome.
o Acanthosis nigricans.
o Polyhydramnios in current pregnancy.

Diagnostic criteria

o Random plasma glucose > 11 mmol/L OR

o A fasting plasma glucose ≥ 5.6 mmol/L, OR
o A plasma glucose of ≥ 7.8 mmol/L two hours after a 75 g OGTT, performed
after overnight fasting, from 24 weeks’ gestation onwards.

Management of GDM

Management is the same as for pregestational diabetes mellitus except:

 Ophthalmologic examination is usually not required

 Some women can be successfully treated with diabetic diet alone
 Insulin is usually stopped after delivery
 A 75 g OGTT is usually done 6 weeks after delivery, or an HbA1C at 12
weeks postpartum
 117

THYROID DISEASE

Most pregnant women with thyroid disease are already on treatment when they
present for antenatal care. Women with recent onset of goitre, thyroid nodule, or
with clinical evidence of thyroid dysfunction require investigation in consultation
with specialist endocrinologists. Pregnant women with thyroid disease are best
managed in a combined obstetric/endocrine clinic

Hyperthyroidism

 Most cases are diagnosed as autoimmune Graves’ disease

 Antithyroid drugs (carbimazole) are effective in controlling hyperthyroidism
 Monitor thyroid functions regularly throughout the pregnancy
 Ensure that the maternal haemoglobin is ≥11 g/dL
 Follow the fetus with ultrasound scans to detect goitre or growth restriction
 Mode of delivery should be dictated by obstetric considerations
 Inform the anaesthetists of a planned caesarean section
 Inform the paediatricians that the woman is hyperthyroid – take cord blood at
delivery for TSH &T4
 Beware of postnatal exacerbations of hyperthyroidism
 The most serious maternal complications are thyroid storm and heart failure

Hypothyroidism

 Most cases have had thyroid gland destruction caused by autoimmune

disease (Hashimoto’s thyroiditis), surgery or radiation
 Thyroid hormone replacement is effective and safe in pregnancy
 Expect normal pregnancy and delivery in well controlled patients
 Beware of postnatal exacerbations of hypothyroidism
 The most serious maternal complication is myxoedema coma
 118

HEART DISEASE

Heart disease in pregnancy is associated with a significant increased risk of

maternal and fetal morbidity and mortality. At the first antenatal visit, all women
must be asked about a history of heart disease, and should undergo a clinical
examination of the cardiovascular system.

Symptoms of heart disease include:

 Progressive dyspnoea
 Orthopnoea
 Haemoptysis
 Palpitations
 Chest pain
 Dizziness

Signs of heart disease:

 Rapid (100/min) or irregular heart rate
 Cyanosis
 Clubbing
 Heart murmurs
 Cardiomegaly

ANTENATAL CARE

All women with a history, or with symptoms and signs of heart disease, should be
referred, ideally to an obstetric cardiac clinic, run jointly by an obstetrician and a
cardiologist.

Principles of antenatal care

 All pregnant cardiac patients should have an echocardiogram, chest X-ray
and ECG
 A New York Heart Association (NYHA) grading is assigned to each patient
(I = no dyspnoea, II = dyspnoea with moderate exertion, III = dyspnoea with
mild exertion, IV = dyspnoea at rest)
 Termination of pregnancy may be recommended for patients with severe
cardiac disease early in pregnancy (NYHA grade III or IV), cyanotic
congenital heart disease, or those with right-to-left shunt reversal
(Eisenmenger syndrome)
 Women with congenital heart disease require detailed ultrasound scanning at
the Fetal Medicine Unit to identify fetal heart defects
 Infection, anaemia and arrhythmias must be prevented, identified & treated
 Diuretics, vasodilators, beta-blockers or antiarrhythmics are given if required
 Anticoagulation, if needed, is given as described below
 Induction of labour or elective caesarean section are usually recommended
only for obstetric indications
 119

LABOUR IN WOMEN WITH HEART DISEASE

Consider 5 As: Analgesia, Antibiotics, Anticoagulation, Anti-failure measures,

Assisted delivery

First stage

 Admit to a high care area

 Nurse the woman in a semi-Fowler position
 Restrict intravenous fluids - Ringer-Lactate or Normal saline 70 mL/hour
 Give adequate analgesia – pethidine 1 mg/kg IM with metoclopramide 10 mg
IM 4 hourly. Epidural analgesia is useful for cardiac patients without fixed
output states
 Give ampicillin 1 g IV 6 hourly for 4 doses and gentamicin 240 mg IV as a
single dose, as prophylaxis against infective endocarditis
 Vancomycin 1 g IV as a single dose for women allergic to penicillin
 Observe colour, heart rate, BP and respiratory rate hourly
 Auscultate the lung bases 2 hourly
 If augmentation of labour is necessary, give oxytocin in a 200 mL infusion bag

Second and third stages

 Avoid the lithotomy position – the woman must sit up with her legs supported
below the level of her body, by assistants or on chairs
 Perform a forceps delivery or vacuum extraction for NYHA grade III and IV,
unless delivery is rapid and easy
 Local anaesthetics for episiotomy should not contain adrenaline
 Do not give ergometrine in the third stage; use oxytocin 10 units IM
 Give furosemide 40 mg IV after delivery of the baby

Fourth stage and puerperium

 Observe closely for evidence of pulmonary oedema

 Do hourly observations of general condition, respiratory rate, heart rate and
blood for 24 hours
 When stable, transfer to the postnatal ward
 Breast-feeding is encouraged even on long-term anticoagulation
 Offer contraception – long acting depot progestins (medroxyprogesterone
acetate, etonogestrel implant) are safe for women with heart disease
 Delay postpartum sterilization until at least one month after delivery
 Discharge the woman when she is well, with a letter to her doctor or cardiac
clinic
 120

PULMONARY OEDEMA

 Nurse in the semi-Fowler position

 Give oxygen by mask
 Restrict intravenous fluid
 Give furosemide 40 mg IV, and repeat if necessary
 Attach an ECG monitor and pulse oximeter if available
 Seek advice from an internal medicine specialist or anaesthetist if there is no
rapid response to the above measures

PERIPARTUM CARDIOMYOPATHY (PPCM)

 Development of cardiac failure within the last month of pregnancy and the
5 months post-partum.
 Absence of identifiable cause for the cardiac failure
 Absence of recognizable heart disease
 Left ventricular systolic dysfunction (LVEF <45%)
 Possible complications: arrhythmias, PE and congestive heart failure.
 Echocardiogram remains the most important tool for the diagnosis and
follow up for a patient with PPCM
The management is similar to other form of heart failure except in the women
who presents while pregnant where the effects on the fetus should be consider
(avoid ACE inhibitors). The aim of the treatment: improve blood flow to vital
organs, reduce fluid overload, treat abnormal heart rhythms and prevent
complications such as thrombo embolic disease (TED).
 Vasodilators antenatally, ACE inhibitors postpartum
 Diuretics
 B-blockers
 Anticoagulation
 O2 administration

Once stable and before discharge the patient should be strongly counselled
about prognosis, future reproductive health and follow up.

ANTICOAGULATION

Indications for full anticoagulation

 Mechanical heart valve replacement

 Atrial fibrillation
 Tight mitral stenosis (valve area <1 cm2)
 Dilated cardiomyopathy
 Primary pulmonary hypertension
 Known thrombophilias
 121

 Thromboembolism during the pregnancy

 History of two or more previous episodes of thromboembolism

Full anticoagulation in pregnancy

 4-13 weeks: heparin 10 000 units 8 hourly SC

 14-36 weeks: warfarin 2.5-10 mg daily orally
 37-42 weeks: heparin 10 000 units 8 hourly SC

Alternative full anticoagulation regimen

This is preferred for women with venous thromboembolism, and may, in

consultation with cardiologists, be considered for women with mechanical valves.

 Enoxaparin 1 mg/kg 12 hourly SC

 Keep anti-factor Xa levels at 1.0 - 1.2 U/mL (3 hours after injection)

Management of anticoagulated pregnant women

 Order a second trimester ultrasound scan (23 weeks) to exclude fetal

abnormality
 The safest anticoagulation regimen for the woman with a mechanical valve
replacement is warfarin
 For women on warfarin, ensure INR of 2.5 – 3.5 for those with mechanical
valves, and INR 2.0 – 3.0 for women in atrial fibrillation.
 If on warfarin, admit to hospital at 36 weeks to switch her to heparin
 For women on heparin, monitor PTT daily at 12:00, and adjust to 2.0 - 2.5 x
control. Blood for PTT must be taken at the same interval from the last dose
of heparin, half-way between doses
 If on heparin or enoxaparin at term, discontinue these agents 24 hours before
starting induction of labour or commencing elective caesarean section
 Do not give heparin during labour, unless specifically requested by a
consultant or cardiologist
 Epidural and spinal anaesthesia are contraindicated
 Avoid cuts and tears at delivery if possible
 Ensure haemostasis during perineal suturing or at caesarean section
 Women fully anticoagulated on warfarin who present in labour may need
caesarean section to protect the baby against intracranial bleeding. Give 2
units of fresh frozen plasma to prevent maternal intraoperative bleeding
 Restart pre-pregnancy warfarin on the first postnatal day but continue SC
heparin until INR is within therapeutic range, then discharge with follow up
arrangements
 122

Notes on anticoagulants

 The teratogenic effect of warfarin is limited to between the 4 to 12 weeks

gestation, resulting in a warfarin embryopathy.
 It may also result in spontaneous fetal cerebral bleeds in the 2nd trimester
 For acute bleeding resulting from warfarin use, the antidote is fresh frozen
plasma 1-2 units. Vitamin K 5 mg IV takes effect in 6-12 hours
 Heparin/enoxaparin does not cross the placenta, but may (especially
unfactionated heparin) cause maternal alopecia, osteoporosis and alopecia
 Heparin antidote is protamine sulphate: give 1 mg for each 50 units of the
hourly dose of continuously administered heparin or 1 mg for each 100 units
of the last intermittent dose. Dilute in 20 mL saline and give IV over 5 minutes

THROMBOEMBOLIC DISEASE

One previous deep vein thrombosis (DVT) or pulmonary embolism (PE)

The risk of TED should be discussed with the women at risk, ideally as pre-
pregnancy counselling and with a prospective management plan. Women with a
previous history of TED ( except if related to a major surgical procedure and in
the absence of other risk factors), should be offered thromboprophylaxis
throughout pregnancy including the puerperium for at least 6 weeks post-partum
regardless of the mode of delivery.

 Give heparin 5000 units SC twice daily (or enoxaparin 40 mg SC daily) up to

delivery, and warfarin postpartum for 6 weeks. Adjust warfarin to an INR of
2.0 - 3.0
 Prescribe graduated elastic compression stockings

Two previous episodes of DVT or PE

 Consult with a haematologist, for thrombophilia screening (antithrombin III,

protein C, protein S, antiphospholipid antibodies)
 Prescribe full anticoagulation with enoxaparin or heparin and/or warfarin as
shown above
 Prescribe graduated elastic compression stockings

DVT or PE in the current pregnancy

A women with clinical signs and symptoms of thromboembolic disease should

start treatment immediately while objective testing is performed unless
treatment is contraindicated.
 DVT
Iliofemoral/popliteal duplex ultrasound should be done where there’s a clinical
suspicion of DVT. If the u/s is negative but the clinical suspicion very high,
stop the anticoagulation treatment and repeat the test 3 – 7 days later.
 123

 PE
Women with signs/ symptoms of PE should have a Chest X-ray and ECG
performed. A ventilation/perfusion (V/Q) scan or computerized tomography
pulmonary angiogram (CTPA) should also be considered.

 Acutely ill patients should be managed in a high care area, with support and
advice from internal medicine specialists
 LMWH should be commenced immediately until diagnosis is confirmed. It
should be given according to women’s weight (1 mg/kg/dose 12 hourly)
 Treatment with therapeutic dose of LMWH should be continued during the
remainder of the pregnancy and at least 6 weeks post-partum, or until at least
3 months of treatment has been completed.
 Prescribe graduated elastic compression stockings

ASTHMA

ANTENATAL CARE

The management of asthma in pregnancy does not differ from that of non-
pregnant women. Treatment must be optimised to prevent attacks, which may
cause fetal hypoxia and intrauterine death. Use peak flow meters wherever
possible to monitor response to drug therapy.

 Patients with infrequent attacks who are well controlled on inhaled medication
(steroids and beta-agonists) can be managed at their local clinics
 Frequency of antenatal visits is the same as for uncomplicated pregnancies
 Difficult patients may be referred to internal medicine specialists for advice

LABOUR AND POSTPARTUM CARE

 Give hydrocortisone 100 mg IV 6 hourly for 4 doses to all women who have
used oral steroids during pregnancy
 Use prostaglandins, nonsteroidal anti-inflammatories, pethidine and
ergometrine with caution. Beta-blockers are absolutely contraindicated.
 Asthma attacks in labour require admission, continuous oxygen, and
aggressive management (below)

CHRONIC PERSISTENT ASTHMA

Step-up therapy is recommended, increasing according to severity. Prescribe

inhaled steroids for women who need to use a bronchodilator inhaler more than
twice per week. Most asthmatic patients will require inhaled corticosteroids for
maintenance therapy. Use peak flow meters to monitor response in patients who
are wheezing.
 124

Step-up therapy of chronic persistent asthma

Drugs Notes

Step 1 Inhaled short-acting beta- Ensure the recommended

agonist (SABA) e.g. salbutamol maximum dosage in the
as necessary package insert is not exceeded
Step 2 Add low-dose inhaled Give ICS 250-500 mcg daily
corticosteroid (ICS) administered in two divided
beclomethasone or budesonide doses;
Step 3 Increase to moderate-dose ICS Give ICS 500-1000 mcg daily
or add long-acting beta-agonist
(LABA) e.g. salmeterol
Steps 4-6 Increase to high-dose ICS ± Give ICS >1000 mcg daily in
LABA ± montelukast; two divided doses; Consider
last resort is oral prednisone referral to physician or
pulmonologist

MANAGEMENT OF AN ACUTE ASTHMATIC ATTACK

 Admit to High Care Area, nurse sitting up, and give mask oxygen to keep
oxygen saturation ≥90%
 Use a peak flow meter to monitor response
 Nebulize with short-acting beta agonist with or without ipratropium bromide)
 Give hydrocortisone IV
 With poor response to the above, add magnesium sulphate IV
 Consult with internal medicine specialists if management is not successful

Drugs used in the management of an acute asthmatic attack

Drug Dose
Short-acting beta-agonist Salbutamol 5 mg or fenoterol 1 mg (available as unit
nebulization (always) dose vials) every 20 minutes until response is
satisfactory
Ipratropium nebulization 0.5 mg with salbutamol or fenoterol in the nebuliser
(recommended) solution
Corticosteroids Hydrocortisone 100-200 mg 4-6 hourly IV until
(recommended) response is satisfactory, then oral prednisone 30 mg
daily for 7-14 days
Magnesium sulphate 1-2 g IV over 20 minutes (maximum 2 doses 12
(recommended) hours apart)
 125

JAUNDICE

CAUSES OF JAUNDICE IN PREGNANT WOMEN

Pregnancy related

 Severe pre-eclampsia or HELLP syndrome

 Acute fatty liver of pregnancy
 Severe hyperemesis gravidarum
 Intrahepatic cholestasis of pregnancy
 Severe sepsis

Not related to pregnancy

 Acute viral hepatitis

 Drug induced jaundice
 Haemolysis including malaria
 Other causes e.g. chronic liver disease or enzyme defects

MANAGEMENT

Making a diagnosis

 Ask about onset, duration, and associated symptoms e.g. pruritus, pain,
vomiting, headache
 Determine the colour of the stools and urine
 Ask about travel history if there is fever, anaemia or thrombocytopaenia
 Find out what medications have recently been taken
 Look for pyrexia, anaemia, hypertension, hepatosplenomegaly
 Test the urine for protein, ketones, urobilinogen and bilirubin
 Take blood for FBC and malaria smear, malaria antigen, U&E, INR, LFT,
glucose and hepatitis studies

Treatment

1. Determine the cause of the jaundice and treat accordingly

2. Discuss management with a senior registrar or consultant
3. Call an internal medicine specialist for assistance with causes of jaundice
unrelated to pregnancy
4. Patients with acute fatty liver and pre-eclampsia/HELLP syndrome require
delivery
5. Patients with acute viral hepatitis may deteriorate after delivery and should
not have labour induced or undergo caesarean section, unless obstetrically
indicated
 126

EPILEPSY

Most pregnant epileptic patients are already on treatment. Those who have been
off treatment and fit-free for over 2 years need not be on medication. Epileptic
management is best achieved in a dedicated obstetric epileptic clinic

 Request an 18-22 week detailed ultrasound scan to exclude fetal anomalies

 The drug of choice is carbamazepine, usually at 200-400 mg 12 hourly orally
 Monitor carbamazepine blood levels in poorly controlled epileptics. The
therapeutic range is 8-12 g/mL
 Use monotherapy wherever possible (carbamezapine or lamotrigine)
 Do not change non-carbamazepine treatment (e.g. phenytoin) if it is effective
 Give folic acid 5 mg orally daily throughout the pregnancy
 If convulsions occur in a compliant patient, increase the evening dose of
carbamazepine, or add phenobarbitone 30-60 mg or clonazepam 0.5 mg
orally as evening doses if necessary.
 Obstetric care is the same as for non-epileptic women
 Do not omit doses of anti-epileptic drugs, even during labour
 At delivery, inform the paediatric doctors that the woman is epileptic
 Breastfeeding is safe with the anticonvulsants mentioned above
 After delivery, readjust treatment to pre-pregnancy doses

Convulsions occurring for the first time in pregnancy

 Admit to hospital
 Consider and rule out eclampsia as a cause
 Consult an internal medicine specialist or neurologist
 Do skull x-ray, and take blood for FBC, U&E, calcium/magnesium/phosphate,
antinuclear factor, anticardiolipin antibody, lupus anticoagulant, cysticercosis
serology, syphilis serology and HIV before referral
 Electroencephalogram and brain imaging may be ordered by the neurologist

Treatment of status epilepticus

 Turn patient to left lateral, protect airway and give oxygen by mask
 Start an IV infusion – if not possible, give diazepam 10-20 mg rectally
 Check blood glucose level and give 50% dextrose 50 mL IV if glucose is low
 Give lorazepam 0.1 mg/kg (5-10 mg) at 2 mg/kg, or diazepam 0.2 mg/kg (10-
20 mg) IV over 2 minutes at 5 mg/minute, or. Beware respiratory depression
 Except in the first trimester, give phenytoin 15-20 mg/kg (1000 mg) IV
infusion in 200 mL normal saline over 30 minutes; repeat 125 mg IV 8 hourly
 If phenytoin is not effective, or as an alternative, give phenobarbital 20 mg/kg
IV at 100 mg/minute; repeat 1 mg/kg IV 6 hourly
 Call for neurology support, and consider paralysis and ventilation if seizures
cannot be controlled after one hour
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Chapter 7 Infectious conditions

SEXUALLY TRANSMITTED INFECTIONS

ABNORMAL VAGINAL DISCHARGE

Perform a vaginal speculum examination to observe the discharge and inspect

the cervix. If no speculum is available, simple digital vaginal examination can be
done.

 If vaginal candidiasis (thrush) is observed, give clotrimazole single-dose

pessary 500 mg to be inserted in the vagina that evening. Advise the woman
to avoid washing with soap or antiseptics

 If a nonspecific yellow/green or offensive discharge is observed, give

metronidazole 2 g orally as a single dose (for trichomoniasis or bacterial
vaginosis). In the first trimester, give clotrimazole pessary 500 mg instead of
metronidazole

 If a mucopurulent discharge from the cervical os is observed on speculum

examination, add ceftriaxone 250 mg IM (mixed with 0.9 mL lidocaine 1%),
and azithromycin 1 g orally as a stat dose. Do not use ciprofloxacin or
doxycycline in pregnant women

GENITAL ULCERS

 Give benzathine penicillin 2.4 million units IM (mixed with 6 mL lidocaine 1%)
as a single dose (for syphilis) and azithromycin 1 g oral single dose (for
chancroid)
 For pregnant women who are allergic to penicillin, consider penicillin
desensitization and then give penicillin (page 128)
 Check or repeat RPR (if initially negative)
 Encourage the woman to send her partner for examination and treatment
 Follow up in 1-2 weeks to assess response
 For ulcers that appear to be caused by genital herpes, give acyclovir 400 mg
8 hourly for 7 days
 Further details on syphilis treatment are given on page 128.
 128

GENITAL WARTS

These are caused by the human papillomavirus and are sexually transmitted.

 Do not attempt to treat the warts

 Podophyllin is contraindicated in pregnancy
 For large foul-smelling and infected warts, try metronidazole 400 mg 3 times
daily orally for 7 days , or local applications with crushed metronidazole
powder, vinegar, and/or honey or golden syrup
 Reassure the woman that the warts may resolve after the pregnancy and can
be treated postnatally if they persist
 Surgical excision of warts may be considered in exceptional cases – discuss
with an experienced consultant
 Consider elective caesarean section when warts are so large as to obstruct
vaginal delivery

SYPHILIS AND POSITIVE RPR TESTS

 Treat all women with positive RPR, irrespective of titre values

 Do not do specific treponemal tests (FTA-ABS, TPHA, TPAB) unless there is
a strong suspicion of a false positive RPR, and follow up is guaranteed
 Give benzathine penicillin 2.4 million units IM (mixed with 6 mL lidocaine 1%)
once weekly for 3 doses
 Repeat RPR 3 months after the last dose of penicillin to exclude reinfection.
Retreatment is only necessary if the titre has increased. Give one injection
only
 Penicillin desensitisation is recommended if the RPR titre is 1:16 for women
who are allergic to penicillin. If a macrolide was used, the baby should be
treated with penicillin after delivery
 Notify partner to go for examination and treatment

Penicillin desensitization

This is done for pregnant women who are allergic to penicillin and who have a
high RPR titre (1:16). This is necessary because oral erythromycin may not
transfer adequately to the fetus.

Penicillin desensitisation takes about 4 hours, and is followed by close

observation until the following day. Use oral penicillin V, with a starting dose of
100 units, doubling every 15 minutes. Give the benzathine penicillin injection 30
minutes after the last oral dose. Second and third doses are given at weekly
intervals one hour after a 400 000 unit dose of oral penicillin V, with similar
precautions as described below.
 129

Oral desensitization regimen

Dose Penicillin V Amount Units Cumulative

(units/mL) (mL) dose (units)
1 1000 0.1 100 100
2 1000 0.2 200 300
3 1000 0.4 400 700
4 1000 0.8 800 1500
5 1000 1.6 1600 3100
6 1000 3.2 3200 6300
7 1000 6.4 6400 12 700
8 10 000 1.2 12 000 24 700
9 10 000 2.4 24 000 48 700
10 10 000 4.8 48 000 96 700
11 80 000 1.0 80 000 176 700
12 80 000 2.0 160 000 336 700
13 80 000 4.0 320 000 656 700
14 80 000 8.0 640 000 1 296 700

Precautions with desensitization

 Admit to a high care area

 Get informed consent
 Place an IV line
 Measure 4 hourly temperature, hourly BP and ½ hourly heart and respiratory
rate
 Treat mild allergic reactions with promethazine 25 mg IV, and continue with
the regimen

HIV INFECTION IN PREGNANCY

Without antiretroviral drug treatment, infection with human immunodeficiency

virus (HIV) results in acquired immune deficiency syndrome (AIDS), and has a
high risk of transmission of the virus from an infected pregnant or breastfeeding
woman to her baby.

All women who book for antenatal care should be offered HIV testing, according
to the principles of provider-initiated HIV counseling & testing (PICT). Only
women who have a documented positive HIV status, and are on antiretroviral
therapy (ART) are not offered an HIV test. Rapid antibody tests are used. A
positive test is confirmed using another rapid HIV test kit. If one result is positive
and the other is negative, the results are indeterminate and an ELISA must be
done to confirm the HIV status.
 130

Counselling a pregnant woman about being HIV positive

1. Counselling is best provided by a trained counsellor

2. Establish what the woman knows about HIV
3. Give information on how the virus is transmitted
4. Discuss the symptoms, signs and progression of the disease
5. Explain the importance of CD4 count & viral load (VL) monitoring
6. Discuss the benefits and potential side-effects of ART
7. Explain the risk of mother-to-child transmission of HIV and how this may be
reduced: safe infant feeding choice and antiretrovirals (ARVs)
8. Discuss who the woman may want to tell about the result – disclosure is
associated with better treatment adherence
9. Discuss condom use and other safe sex practices to prevent transmission to
and from the partner, and also discuss partner testing
10. Discuss future fertility plans, and further contraception

Antenatal care

Antenatal care is usually conducted at the woman’s local clinic, but women with
obstetric risk factors will attend hospital as is usual practice.

Clinical assessment:

 Ask about chronic illnesses in the past, and about current health
 Ask about the presence of any psychiatric illness
 Screen for TB: ask about cough, weight loss, night sweats and fever
 On physical examination, look for evidence of opportunistic infections: oral
candidiasis, herpes zoster, and pulmonary TB
 Look for evidence of sexually transmitted infections and treat appropriately
 Stage the woman according to the World Health Organization staging system

Investigations:

 Take blood for CD4 count, Hb and creatinine at ART initiation, and follow up
in one week for results
 Once on ART, do a VL every 3 months during pregnancy
 Investigate for TB if screen positive

Treatment:

 Initiate ART, preferably on the day of diagnosis

 Give the usual antenatal supplements, such as folate, iron and calcium
 Give isoniazid preventive therapy (IPT) 300 mg with pyridoxine 25 mg daily
for 12 months to all women initiated on ART who screen TB-negative
 131

 Give cotrimoxazole 2 tablets orally daily to women with CD4 cell count
<200/mm3
 Do a serum cryptococcal antigen (CRAG) on asymptomatic women with CD4
<100 cells/mm3. If positive, start oral fluconazole pre-emptive therapy
o Fluconazole 800 mg daily for 2 weeks
o Then 400 mg daily for 8 weeks
o Then 200 mg daily, until her CD4 cell count has risen above 200
cells/mm3

Note: fluconazole should not be used in the first trimester, unless it is used for
the treatment of cryptococcal meningitis.

Continuing antenatal care:

 All women who test HIV negative in early pregnancy should be offered a
repeat test every 3 months, at the onset of labour, at 6 weeks postpartum,
and every 3 months during breastfeeding.
 Women on ART should have VL monitoring every 3 months throughout
pregnancy, then 6-monthly during breastfeeding
 Creatinine is repeated at 3 months, 6 months, 12 months, then annually while
on TDF
 If there is a need for antenatal invasive procedures, initiating ART 6 weeks
before the procedure gives some reassurance of viral suppression to allow
the procedure to be done
 Consider elective caesarean section for women likely to require an
emergency caesarean section in labour, e.g. previous caesarean section
 HIV infection alone is not a valid indication for Caesarean section.

ART AND PREVENTION OF MOTHER-TO-CHILD TRANSMISSION (PMTCT)

All HIV-infected pregnant women are offered lifelong ART, irrespective of CD4
count or HIV disease stage.

ART regimens

The first-line regimen comprises a fixed dose combination (FDC) tablet

containing:
 Tenofovir (TDF) 300 mg, Emtricitabine (FTC) 200 mg, and Efavirenz
(EFV) 600 mg, taken once at night
 Alternative ART regimens include Abacavir (ABC) in place of TDF for
women with renal dysfunction (serum creatinine >85 µmol/L)
 Nevirapine (NVP) in place of EFV for women with active psychiatric
illness, provided her CD4 <250 cells/mm3
OR
 Lopinavir/ritonavir (LPV/r) if her CD4 ≥250 cells/mm3
 132

 While NVP is rarely initiated in pregnancy because of the risk of life-

threatening toxicity, women who become pregnant on NVP and are stable
on treatment may continue with NVP.

Labour and delivery

Women must not miss their ARV doses during labour. During labour for women
who are unbooked & diagnosed HIV positive:

 Give single-dose NVP 200 mg orally at onset of labour

 Give single-dose TDF 300 mg with FTC 200 mg orally at onset of labour
 Give AZT 300 mg 3 hourly orally
 Commence lifelong ART within 24 hours after delivery

HIV prevention and testing for infants

All HIV-exposed infants, regardless of infant feeding method and whether the
mother is on ART or not, should receive daily NVP syrup for the first 6 weeks of
life.

NVP syrup is stopped at 6 weeks in formula fed infants. It is also stopped at 6

weeks if the infant is breastfed and the mother is on ART. If the infant is
breastfed and the mother is not on ART, daily NVP is continued until 1 week after
stopping breast-feeding. The dose of NVP syrup changes as the infant grows.

All HIV-exposed infants must have an HIV PCR test done at birth, and again at
10 weeks of age, and, if positive, must be referred for ART initiation immediately.
Infants who have received extended NVP prophylaxis, i.e. 12 weeks, the PCR is
done at 18 weeks. If they test negative and are breastfed, the HIV test is
repeated 6 weeks after stopping breastfeeding. All HIV-exposed infants who
tested negative previously must have an HIV antibody test at 18 months.

Infant’s age Nevirapine syrup dose

Birth to weeks Birthweight <2500 g: 1.0 mL (10 mg) daily

Birthweight ≥2500 g: 1.5 mL (15 mg) daily

Notes on ARVs

Minor side-effects are common at ART initiation, and usually resolve after a few
weeks, and are not a reason to discontinue treatment. Patients should be
advised to report to their clinics any side-effects they develop on ARVs,
especially skin rashes, persistent vomiting, jaundice or severe malaise, and be
referred if there are concerns about the seriousness of the side effects. ART
 133

should only be interrupted or switched in consultation with an HIV treatment

expert.

Interactions may occur between ARVs and other medications, and this may be
due to similar side effect profiles or altered metabolism. Consult a reference
guide or HIV expert for advise.

Antiretrovirals and common side-effects (not a comprehensive list)

Tenofovir (TDF): renal dysfunction, only use if serum creatinine <85 µmol/L

Lamivudine (3TC) and Emtricitabine (FTC): side-effects not common, generally

well-tolerated

Efavirenz (EFV): central nervous system effects – dizziness, insomnia, bad

dreams, also rash, hepatitis

Abacavir (ABC): drug-induced hypersensitivity reaction (uncommon)

Nevirapine (NVP): rash including Stevens-Johnson syndrome, hepatitis. Avoid

NVP in women with CD4 cell count >250 cells/mm3

Lopinavir/ritonavir (LPV/r): diarrhea, nausea, dyslipidaemia

Labour and delivery

Labour is generally managed in the same way as for women who are HIV-
negative.

 Do not rupture membranes for poor progress unless her VL is undetectable

 Avoid using penetrating fetal scalp electrodes for heart rate monitoring
 Avoid episiotomy wherever possible

Postpartum care

 Give normal postpartum care, irrespective of mode of delivery

 Inform the woman about handling and disposal of soiled pads and linen
 Treat infections promptly and aggressively
 Give information about advantages and disadvantages of breast and formula
feeding – strongly discourage mixed feeding
 All HIV-positive women should be encouraged to exclusively breastfeed for
the first 6 months, with complementary feeding only from 6 months and
breastfeeding continued until 12 months, unless contraindicated
 Give contraceptive advice and discuss sterilization if appropriate
 134

Women with advanced HIV disease

The following problems may be expected:

 Opportunistic infections, e.g. meningitis, pneumonia, TB, chronic diarrhoea

 Severe puerperal sepsis
 Spontaneous preterm labour with or without chorio-amnionitis
 The need for preterm elective delivery in a terminally ill pregnant woman –
requires a discussion with the family
 Rapid deterioration and death after delivery, especially after spontaneous
preterm labour
 Possible need for disclosure of the illness to the relatives

Treatment is individualized according to each patient’s specific disease profile

and family circumstances, in consultation with physicians and infectious disease
or HIV treatment specialists.
 135

HIV infected not on ART

WHO staging, screen for
TB, take blood for CD4,
creatinine

History of renal disease

No history of psychiatric
or renal disease

Start FDC the same day One week later

(TDF/FTC/EFV) CD4 and creatinine
results

Creatinine ≤85 Creatinine >85

Continue FDC as ABC + 3TC +

lifelong ART EFV

Investigate for
renal disease

LIFELONG ART FOR ALL

HIV-INFECTED PREGNANT
& BREASTFEEDING
WOMEN
 136

GROUP B STREPTOCOCCAL INFECTION

Group B Streptococcus (S. agalactiae) colonises up to 30% of pregnant women,

and causes early onset infection in 0.2% of newborns. Routine culture of the
maternal rectum and vagina at 35-37 weeks is not practiced in public hospitals.

Risk factors for neonatal early-onset Group B Streptococcal infection

 Spontaneous preterm labour (<37 weeks)

 In labour, with membranes ruptured ≥18 hours
 Intrapartum pyrexia ≥38 degrees C
 A previously affected baby with neonatal early onset GBS infection
 Urine, vaginal or rectal cultures positive for GBS

Women with these risk factors must be treated during labour with ampicillin 2 g
IV as a single dose, followed by 1 g IV 4 hourly up to delivery. Penicillin-allergic
women may receive intravenous azithromycin or vancomycin.

URINARY TRACT INFECTION

CYSTITIS AND ASYMPTOMATIC BACTERIURIA

Cystitis presents with severe urinary discomfort and/or frequency. There may be
some lower abdominal tenderness. There is usually no fever and little malaise.
Urine dipstick testing may show nitrites, or leukocytes with/without blood. Urine
MCS may identify the infecting organism.

Asymptomatic bacteriuria (AB) is defined as a positive culture of a single

organism with ≥105 colonies/mL with no symptoms. The prevalence is about 5-
10% in pregnancy, with a 40% probability of developing symptomatic urinary tract
infection later in pregnancy. Routine case-finding for asymptomatic bacteriuria is
not practiced in public hospitals.

Management

 For symptomatic women, send a midstream urine specimen for MCS

 Empiric therapy:
o Nitrofurantoin 100 mg orally 6 hourly for 5 days
OR
o Cefuroxime 500 mg orally 12 hourly for 5 days
 Encourage a high oral fluid intake
 MCS results will guide further treatment and antibiotic choice
 Consider follow-up urine culture after treatment, especially in women with
asymptomatic bacteriuria
 Women with recurrent urinary tract infections may need prophylactic
continuous antimicrobial treatment
 137

Taking a midstream urine specimen

Explain the procedure well to the patient, or ask a nurse to assist her with taking
such a specimen, using a sterile plastic container

1. Separate the labia

2. Wipe the urethral opening from front to back with a sterile water swab
3. Avoid touching or contaminating the rim or the inside of the container and lid
4. Hold the container ready, and do not allow it to touch the vulva or thighs
5. Pass urine, and after a few seconds of urine passing out into the toilet, catch
fresh urine from the stream in the container
6. Close the container tightly and submit it as soon as possible for culture

ACUTE PYELONEPHRITIS

This is a common and serious cause of pyrexia in pregnancy. The patient usually
appears ill and has pyrexia and tachycardia, with renal angle tenderness.

Management

 Admit to hospital
 Send a midstream urine specimen for MCS
 Take blood for FBC, U&E and blood culture
 Assess the patient for evidence of preterm labour
 Start ceftriaxone 1 g IV daily, changing to oral treatment 24-48 hours after the
fever subsides. Adjust the antibiotic if necessary according to the MCS
results. Total duration of treatment should be 7 days
 Give Ringer-Lactate solution 3 L/day, or more if the woman is vomiting
 Following recovery, retest urine for MCS to confirm clearance of the infection
 Follow up for urine MCS result at antenatal clinic

PNEUMONIA AND TUBERCULOSIS

ACUTE SEVERE LOWER RESPIRATORY TRACT INFECTION

Ill women with clinical evidence of pneumonia should be admitted to hospital.

There is usually acute onset of fever, chest pain, and productive cough with
typical chest signs on examination.

Investigations

 Chest X-ray
 FBC, U&E, ABG, blood culture, HIV test
 CD4 count if HIV positive
 Sputum GeneXpert & MCS (ignore if Bartlett score <1)
 138

Treatment

 Give co-amoxiclav 1.2 g IV 8 hourly until the temperature has settled for 24
hours, followed by amoxycillin 1 g orally 8 hourly.
 For severe penicillin allergy, give azithromycin 500 mg daily orally
 For acutely ill women with severe pneumonia:
o Give ceftriaxone 2 g IV daily until apyrexial and stable for 24 hours
o Follow with amoxicillin/clavulanic acid 875/125 mg 12 hourly for 5 days
AND
azithromycin 500 mg daily for 5 days
 Attach a pulse oximeter, initially at least. If the oxygen saturation is <90%,
give face mask oxygen. Consider ventilation in ICU if polymask oxygen is
ineffective
 Clinical markers of severe pneumonia:
- evidence of multilobar pneumonia
- respiratory rate >30/minute
- cyanosis
- confusion
- systolic BP <90 mmHg
- renal dysfunction

 Call an internal medicine specialist for advice if the patient is extremely ill or
problematic

SEVERE LOWER RESPIRATORY TRACT INFECTION WITH HIV INFECTION

Manage as above, but consider investigation and treatment for pneumocystis

pneumonia (below) and investigate additionally for TB (below)

PNEUMOCYSTIS PNEUMONIA (PCP)

This presents with dry cough, tachypnoea, and hypoxaemia, usually in HIV
infected patients with CD4 count <200/mm3, or in other categories of
immunocompromised patients. There may be no clinical signs on chest
examination, or bilateral symmetric signs. Chest x-ray usually shows symmetrical
interstitial/ground-glass shadowing.

Drug treatment is cotrimoxazole 80/400 mg in 4 divided doses for 3 weeks

For women with weight <60 kg: 3 tablets 6 hourly
For women with weight >60 kg: 4 tablets 6 hourly

For women with saturation <90%, add prednisone 40 mg orally 12 hourly for 5
days, then 40 mg daily for 5 days, then 20 mg daily for 10 days.
For patients who cannot swallow, give equivalent doses of cotrimoxazole IV, and
hydrocortisone IV in a dose of 5 mg for 1 mg of prednsione.
 139

TUBERCULOSIS

Typical history of pulmonary TB is cough for >2 weeks, weight loss or failure to
gain weight in pregnancy, fever and night sweats, also dyspnoea, tiredness and
haemoptysis. Chest X-ray may show cavitation, nodes, miliary pattern, or
effusions. In immunocompromised patients, lower and mid-zone infiltrates
without cavitation are frequent. Admit women with suspected TB to hospital for
investigation. Seek expert help for complicated or atypical cases.

Essential investigations

 HIV test
 Chest X-ray
 Send 2 sputums, on different days, for TB microscopy & GeneXpert
 For HIV infected women, also send a separate sputum for TB culture

Drug treatment

 Start treatment when the diagnosis is confirmed. Start treatment empirically if

TB is strongly suspected, especially if the woman is very ill
 Notify all cases started on treatment and arrange for continuation of treatment
and transfer to the local clinic
 TB Treatment is usually given for 6 months
 HIV infected women not on ART should be planned for ART initiation two
weeks after starting TB treatment

Starting regimen (intensive phase for 2 months):

Weight <54 kg: RHZE 3 tablets with pyridoxine 25 mg daily

Weight 55-70 kg: RHZE 4 tablets with pyridoxine 25 mg daily
Weight >70 kg: RHZE 5 tablets with pyridoxine 25 mg daily

R = rifampicin 150 mg
H = isoniazid 75 mg
Z = pyrazinamide 400 mg
E = ethambutol 275 mg

The 4-month continuation phase consists of rifampicin and isoniazid only

If drug resistance is found on Gene Xpert, seek advice on alternative anti-TB

drugs. Streptomycin is no longer used for TB treatment.
 140

Extrapulmonary tuberculosis

Extrapulmonary TB is especially common in HIV infected women. TB pleural

effusion is the most frequent form, and may diagnosed on pleural tapping
(exudate, no evidence of malignancy) and treated as for pulmonary TB.
Other forms of extrapulmonary TB are TB meningitis (CSF examination), TB
peritoneum (fluid tapping, and biopsy), TB lymphadenits (clinical or
ultrasound/CT demonstration of lymphadenopathy with fine needle aspiration or
biopsy), TB pericardium and vertebral TB. These may be treated with up to 9
months of TB treatment. TB meningitis needs additional corticosteroid treatment.

MALARIA

Malaria in pregnancy is associated with cerebral complications, hypoglycaemia,

pulmonary oedema and death. There are also risks of miscarriage, preterm birth,
intrauterine death and congenital malaria. Outcome is worse with HIV
coinfection. Consider malaria and take a travel history in any woman who
presents with unexplained fever, and in anaemic woman coming from malaria
endemic areas. All cases of confirmed malaria must be notified.

Diagnosis and blood tests

 Take blood smear for malaria smear and malaria antigen

 If severe malaria is suspected, take blood for FBC, U&E, LFT, ABG and
glucose
 Consider chest x-ray, blood culture or lumbar puncture to exclude other
infections

Management of uncomplicated malaria

In uncomplicated malaria, the woman has an Hb 6 g/dL, a parasitaemia count

≤4% and no organ dysfunction (definition of severe malaria below).

1. Admit to hospital
2. First choice treatment in pregnancy is artemether-lumefantrine 20/120 mg 4
tablets immediately, then 4 tablets 8 hours later. Then 4 tablets 12 hourly for
another 2 days.
3. Always give artemether-lumefantrine with a high-fat liquid (milk)
4. Alternatively, give quinine 600 mg orally 8 hourly and clindamycin 600 mg 12
hourly for 7 days
5. Control pyrexia with oral paracetamol and tepid sponging as necessary
6. Observe vital signs regularly for deterioration to severe malaria
7. If taking quinine, do 4 hourly fingerprick capillary glucose tests, at least for the
first 24 hours
8. Repeat malaria smear after 72 hours and consult if the smear is still positive
9. After 28 weeks, do daily NSTs, follow up to screen for IUGR
 141

Severe malaria

The woman has at least one of the following:

 Parasitaemia count >4%

 Haemoglobin level <6 g/dL
 Circulatory collapse (systolic BP <80 mmHg)
 Adult respiratory distress syndrome – PaO2 <8 kPa in room air
 Convulsions, coma or depressed consciousness
 Urine output <500 mL/day, creatinine >265 μmol/L, or creatinine rising by
>2.5 µmol/L/kg/day
 Jaundice, or transaminase levels more than 3 times normal
 Spontaneous hypoglycaemia <2.2 mmol/L (unrelated to quinine treatment)
 Severe thrombocytopaenia (<50/mm3) or evidence of DIC
 Severe acidosis (lactate >5 mmol/L, serum bicarbonate <15 mmol/L)

Management of severe malaria

1. Admit to a high care area, consult a physician and consider transfer to ICU
2. Note or estimate the woman's body weight
3. Resuscitate, insert an IV line and an indwelling urinary catheter
4. If unconscious, consider hypoglycaemia and meningitis as causes. Intubate if
GCS ≤8 or if responds only to pain (AVPU)
5. Drug treatment:
o Artesunate IV, 2.4 mg/kg at 0, 12 and 24 hours; then daily until patient is
able to tolerate oral therapy
o Administer at least 3 IV doses before switching to oral
artemether/lumefantrine.

If parenteral artesunate is not available:

6. Quinine, IV (1 mL = 300 mg quinine salt).

o Loading dose: 20 mg/kg in dextrose 5% administered over 4 hours.
o Maintenance dose: 8 hours after start of the loading dose, give 10 mg/kg
in dextrose 5% over 4 hours repeated every 8 hours until there is clinical
improvement and the patient can take oral therapy.
o Monitor for hypoglycaemia and dysrhythmias at least 4 hourly.
o If there is significant renal failure increase dose interval to 12 hourly after 48
hours.
7. Transfuse carefully with packed red cells if Hb <6-8 g/dL
8. During IV quinine therapy, monitor blood glucose 4 hourly (treat if <2.2
mmol/L), vital signs and all intake/output hourly, and attach an ECG. Manage
fluids carefully and observe for signs of pulmonary oedema. Consider CVP
monitoring to keep CVP at 0-5 cm water
9. Give broad spectrum antibiotics IV with any suspicion of bacterial coinfection
10. Do daily NSTs if appropriate (gestation ≥28 weeks) and screen for IUGR
 142

Chapter 8 Terminology, audit and statistics

OBSTETRIC TERMINOLOGY

Maternal age

An age of ≥35 years at conception is termed ‘advanced maternal age’ because of

increasing likelihood of trisomies in the offspring, and increased risk of maternal
medical disorders, such as hypertension, diabetes and thromboembolism.

Notes on teenage pregnancy:

 Pregnancy at ≤19 years is termed ‘teenage pregnancy’

 Pregnancy at age <18 years (minors) is of special interest as this is a school-

going age group. According to the law, minors aged 12-17 years may sign
consent for surgery and anaesthesia, but should be assisted in doing so by
an adult guardian

 Pregnancy at age <16 years may result from rape, and raises social and
family issues. All pregnant women aged <16 years should be referred to a
social worker

Gestational age

Gestational age is calculated from the first day of the last menstrual period in a
28-day cycle. Using this method, the estimated date of delivery is calculated as:
(date of first day of last menstrual period) + 9 months + 1 week (Naegele’s rule).

Gestational age is expressed in weeks as the number of completed weeks of

gestation using the first day of the last menstrual period as the reference point.

Gestational age is:

 Preterm at <37 weeks (i.e. up to 36 weeks, 6 days)

 Term at 37-41 weeks (from 37 weeks, 0 days to 41 weeks, 6 days)
 Postterm at ≥42 weeks

There is no legal gestational age threshold for viability, although South African
law considers stillbirths <28 weeks (26 weeks of intrauterine life) to be
miscarriages (not for registration as deaths). The World Health Organization
however defines miscarriages as pregnancies ending at <22 weeks of gestation.
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Birth weights

Birth weights can be classified as follows:

 ≥4000 g: macrosomia
 <2500 g: low birth weight
 <1500 g: very low birth weight
 <1000 g: extremely low birth weight

There is no legal birth weight threshold for viability. All infants born alive receive
care, but neonatal mortality rates are high at <800 g in South African referral
hospitals. Babies <800 g do not usually qualify for ventilator support in neonatal
care units.

Parity and gravidity

Parity refers to the number of pregnancies a woman has completed that have
reached viability (approximately 26 weeks’ gestation), irrespective of whether the
babies were born alive or dead. For example, a woman who has had one
miscarriage at 14 weeks, one stillbirth at term and one preterm birth at 32 weeks
of a baby that is still alive, has a parity of 2 (para 2 or P2). If this same woman
then becomes pregnant, she remains para 2 until she has given birth, and only
then (provided birth occurs after 26 weeks) does she become para 3. A
completed twin pregnancy should be considered as a single parity (disputed by
some authorities who believe a completed twin pregnancy confers two parities).

Gravidity refers to the number of pregnancies, irrespective of gestational age or

completion, that a woman has had. For example, a woman who has had one
previous ectopic pregnancy, one previous miscarriage and two normal term
births, and who is now 11 weeks pregnant, has a gravidity of 5 (gravid 5 or G5).
She also has a parity of 2, and can be termed a para 2 gravida 5 (P2G5).

The following terms are derived from the above definitions:

 Gravida – a pregnant woman (rarely used)

 Nulligravida – woman who has is not and has never been pregnant
 Unigravida – woman who is pregnant for the first time (rarely used)
 Multigravida – woman who has had two or more pregnancies (rarely used)
 Nullipara – woman who has never given birth at a viable gestational age
 Primigravida – woman who is pregnant for the first time
 Primipara – woman who has given birth to her first baby at a viable
gestational age (a ‘primip’)
 Unipara – woman who has had one pregnancy completed at a viable
gestational age (rarely used)
 Multipara – woman who has had 2 or more births at a viable gestational age
(often used to include also women with only one birth – any ‘non-nullipara’)
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 Grand multipara – woman who has had 5 or more births at a viable

gestational age
 Great grand multipara – woman who has had 10 or more births at a viable
gestational age

AUDIT

Audit in maternity care is more than just the gathering of data and statistics: it is
the use of this information to identify problems and devise solutions to those
problems. Audit involves collecting of essential data and holding audit meetings
of all the staff involved in maternity care.

The following information is routinely collected:

 Number of deliveries
 Number of low birth weight babies (<2.5 kg)
 Number of stillbirths
 Number of early neonatal deaths (died in the first 7 days)
 Number of caesarean sections and assisted deliveries
 Number of multiple pregnancies
 Number of women <18 and 35 years of age
 Maternal deaths

The above data are summarised and presented at regular morbidity and mortality
(M&M) review meetings, preferably held weekly at referral hospitals. All maternal
deaths and selected cases of perinatal morbidity or mortality are also discussed.
All doctors working in the maternity service should attend these meetings.

ESSENTIAL STATISTICS

All community health centres and hospitals should calculate their low birth weight
rates, stillbirth rates, early neonatal death rates and perinatal mortality rates on a
monthly basis. Annual summaries can be made at the end of each year. Babies
that weigh <1 kg at birth are usually excluded from these calculations

Low birth weight rate = number of babies <2.5 kg at birth divided by all births in
a given time period. This is expressed as a percentage (e.g. 15%).

Stillbirth rate = number of stillborn babies divided by all births in a given time
period. This is expressed as a proportion of a thousand (e.g. 17/1000).
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Early neonatal death rate = number of babies who died in the first 7 days after
delivery divided by all live births in a given time period. This is expressed as a
proportion of a thousand (e.g. 13/1000).

Perinatal mortality rate = number of stillborn babies plus the number of early
neonatal deaths divided by all births in a given time period. This is expressed as
a proportion of a thousand (e.g. 30/1000).

The perinatal mortality rate is the best measure of total perinatal care in a region
and reflects the characteristics of the community served and its obstetric health
service. Perinatal mortality rates in South Africa range from less than 10/0000 in
affluent and well served communities to 80/1000 in impoverished areas with poor
health services. As the low birth weight rate is a measure of the socioeconomic
status of a community, the perinatal index may be calculated to control for the
influence of socioeconomic conditions.

Perinatal care index = perinatal mortality rate (per thousand) divided by the low
birth weight rate (as a percentage). A high perinatal care index indicates
problems in perinatal care in a region or hospital. From the above examples, the
perinatal care index is 30 divided by 15 = 2.0. A perinatal care index <2.0 is
satisfactory for most South African government hospitals, but all institutions
should strive for an index of 1.

Maternal death = death of a woman while pregnant or within 42 days after the
end of a pregnancy

Direct cause of maternal death = death resulting from a condition specific to

pregnancy, e.g. from pre-eclampsia, puerperal sepsis.

Indirect cause of maternal death = death resulting from a condition that is not
specific to pregnancy, but where pregnancy may have aggravated the condition,
e.g. cardiac disease, HIV disease, diabetes mellitus.

Maternal mortality ratio = number of maternal deaths divided by all live births
recorded in a given time period. This is expressed as a ratio of deaths against
one hundred thousand live births (e.g. 150:100 000).

PERINATAL DEATHS

These include all stillbirths, and neonatal deaths in the first 7 days after birth, of
babies weighing 500 g or more.

1. Details of all perinatal deaths should be collected daily and entered on the
death forms. Stillbirths are identified in the labour ward register and neonatal
deaths are found in the registers of the neonatal unit
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2. This data should be entered into the Perinatal Problems Identification

Programme (PPIP) software, for analysis, reference and presentation

MATERNAL DEATHS

Maternal death is defined as death of a woman while pregnant or within 42 days

of delivery. This is, by law, a notifiable event in South Africa.

Procedure for maternal death

1. The nursing staff usually arrange notification of the next of kin of the
deceased
2. All maternal deaths must be reported as soon as possible to the head of
department by the doctor on duty at the time of the death
4. The relatives should be counselled by the doctors and nurses involved and, if
necessary, asked for permission to submit the body for autopsy
5. The case should be discussed at the next M&M meeting
6. The maternal death must be notified to the provincial authorities on the
maternal death notification form

Procedure for autopsy after maternal death

1. Inform the departmental secretary as soon as possible about plans for

autopsy
2. Counsel the next of kin about the need for autopsy and ask their permission
3. Complete the autopsy consent form with the next of kin
4. Complete the hospital autopsy application form
5. Complete the laboratory services autopsy request form
6. Contact the pathology registrar on duty to arrange any further details
7. All completed forms are taken to the mortuary
8. A doctor from the department should be in attendance at the autopsy

MATERNAL DEATH NOTIFICATION

Maternal deaths are, by law, notifiable. A maternal death is defined as the death
of a pregnant woman, irrespective of gestation, or the death of a woman less
than 42 days after the end of her pregnancy. Whether or not the death is related
to the pregnancy, notification is mandatory. At each institution that offers care to
pregnant women, a person (doctor or midwife) should be nominated to take
responsibility for the notification of maternal deaths, and should keep a supply of
maternal death notification forms, which are available from provincial directorates
of maternal and child health.
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Procedure for maternal death notification

1. Complete the maternal death notification form

2. Attach photocopies of all the deceased’s clinical notes
3. Place the notification form and the photocopied notes in an envelope, clearly
labelled ‘confidential’
4. Send the envelope by courier to the Gauteng provincial maternal and child
health directorate, within 7 days of the death
5. Keep the original clinical notes in a safe place
6. Keep a photocopy of the notification form in a safe place, separate from the
clinical notes

All maternal deaths are assessed by provincial assessors who forward their
assessments to the National Committee for Confidential Enquiries into Maternal
Deaths (NCCEMD). All notifications and assessments are treated in strict
confidence and are destroyed after entry into the Confidential Enquiries
database. The hospital and health workers involved in the maternal death
cannot be identified from the Confidential Enquiries database.

The NCCEMD regularly releases publications in which maternal death statistics

and trends are presented.

AUDIT MEETINGS

Weekly or monthly M&M review meetings should be held in all institutions

providing maternity care, and be attended by all doctors and midwives directly
involved in the care of pregnant women.

Content of M&M meetings

 Presentation and discussion of weekly (or monthly) statistics

 Presentation and discussion of maternal deaths and perinatal deaths, and

cases of severe morbidity or ‘near-miss’: the emphasis is on identifying
problems and finding solutions to these problems. The meetings should not
be used to identify ‘culprits’, as this discourages honesty and prevents
identification of problems. In the discussion of a possible avoidable factor
that led to a death, what was done is much more important than who did it.
Audit of deaths may follow the format used in the Confidential Enquiries into
Maternal Deaths

 Discussion of any problems that relate to the clinical care of pregnant women
in the unit
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ESSENTIAL AUDIT OF A PERINATAL OR MATERNAL DEATH

Identify:

1. The primary cause of death

2. The final and contributory causes of death
3. Avoidable factors related to the patient, her family or her community
4. Avoidable factors related to the health service administration or infrastructure
5. Avoidable factors related to the health care itself

Then propose solutions to any problems identified.