High risk pregnancies such as seen with
-Bad obstetric history e.g. recurrent and unexplained still-births
-Intrauterine Growth Restriction
Fetal kick chart
A daily count of perceived fetal movements from about 30 weeks gestation is a simple and inexpensive routine screening method for monitoring fetal wellbeing. A warning signal is when there are fewer than 10 movements in a 12 hour period.
Ask women to record fetal kicks over a two hour period in the morning. If she can feel three or more movements then she repeats again the same the next day. If however she feels less than three or absent fetal movements, she repeats the recording of fetal kicks for a two hour period in the evening. If they are still reduced she is advised to come to hospital first thing in the morning for a Non Stress Test.
-Reduced fetal movements often but not invariably precedes Intrauterine Fetal Death, in some cases, by several days
-Non-reassuring fetal movement assessment (e.g. <10 kicks in 12 hrs) means further fetal assessment is needed e.g. Non StressTest
-Mother lies on her lateral side and counts distinct Fetal Movements, 2 hours in the morning and 2 hours in the evening.
-It is reassuring if fetal movements are greater or equal to previously established baseline count.
-False positive rate is high and therefore we do a Non Stress Test whenever a woman complains of reduced fetal movements.
We do a non-stress test (NST) loosely termed CTG, because we record fetal heart rate pattern in response to fetal movements and not to a uterine contraction. In high risk pregnancies, where there is concern about babies growth and/ or wellbeing you should request a weekly or even twice weekly NST from about 30 weeks. There may be a midwife to do this but because of shortage it may mean that the SRMO/SHO may need to do it. Therefore be familiar with how it is performed. Before doing a NST, the patient should be in lateral tilt and should not smoke.
Four parameters to look at when reading a NST:
-Baseline fetal heart rate- this should be 110-160 per min
-Baseline variability(by how much does the fetal heart rate vary above and below this baseline)- Normally >5
-Are there any accelerations in response to fetal movements? An acceptable acceleration should go up by 15 beats and should last for 15 secs from start to finish.
-Are there any decelerations? Beware of loss of contact with fetal movements.
1.REACTIVE - normal baseline, normal baseline variability, no decelerations and at least 2 accelerations in 20 min - good sign
2.Non-reactive trace - normal baseline, normal baseline variability, no acceleration and no decelerations- carry on with trace for longer period or stimulate baby by manipulation and repeat.
3. Flat trace - normal baseline, baseline variability less than 5, no accelerations and no decelerations - by itself this may not mean hypoxia but if associated with any other abnormality, it is a bad sign.
4. Abnormal trace - any of above with decelerations. Whenever you see decelerations please check that the woman was not lying on her back during the NST. If in doubt repeat with woman on her side.
If you request a NST, it is the duty of the SRMO/SHO to ensure that every effort is made to read it and relay information to her. If there are any problems, please contact Registrar for firm or the Registrar on call for the day in LW to discuss further management.
Precautions with NST
-A NST of a pre-term non-compromised fetus is frequently non-reactive
-At 24-28 week EGA: up to 50% NSTs may not be reactive
-By 28-32 week EGA: 15% of NSTs are non-reactive.
-Variable decelerations: may be seen in up to 50% of NSTs; if non-repetitive and brief (<30sec)à don’t indicate fetal compromise and there’s no need for obstetric intervention.
Modified Biophysical Profile (MPP) Rationale
Parameters assessed for the Modified BPP:
A modified BPP is considered normal if
It is considered abnormal if either
Timing/When to initiate Antenatal Fetal Monitoring(AFM)
Starting of AFM is dependent on:
-Prognosis for neonatal survival
-Severity of maternal condition
-Risk of IUFD
There is always a potential for iatrogenic pre-maturity due to false-positive test results. It is usually recommended to start AFM from viability (24-26weeks) for most high-risk patients.
-Frequency of AFM is a function of clinical judgment and several factors.
Response to an abnormal AFM test should always be tailored to the clinical situation
Bleeding from the genital tract occurring at any time after fetal viability, greater or equal to 24 weeks gestation, but before the birth of the child.
1. Placenta praevia
Bleeding from separation of a placenta situated in the lower segment of the uterus.
2. Placental abruption
Bleeding from premature separation of a normally situated placenta.
Risk factors include:
3.Indeterminate haemorrhage or APH of unknown cause Bleeding from slight separation of a normally situated placenta.
3.Bleeding from local lesion of the genital tract
These include cervical erosions, trichomonas vaginitis, cervical polyps, cervical cancer etc. Management
If clinically placental abruption:
-Perform digital vaginal examination
-If cervix not fully dilated
-If foetus is alive and gestation age is over 32 weeks, perform caesarean section
–correct clotting defect prior to operation.
-If foetus is dead or of non-viable gestational age, perform Artificial Rupture of Membranes, start oxytocin and aim to deliver within 6-8 hrs.
-If cervix almost fully dilated deliver vaginally.
If placenta praevia confirmed by previous scan
-Perform caesarean section.
If not a confirmed placenta praevia or not placental abruption
NB:THESE WOMEN ARE AT RISK OF POST PARTUM HAEMORRHAGE.
If bleeding mild to moderate and not life threatening
-Admit to early labour ward for bed rest
-Watch pulse and blood pressure
-4 hourly Fetal Heart Rate, pad and contraction checks
-Blood for haemoglobin, blood grouping
-Sedation may be given if patient anxious, 10 mg diazepam orally or im.
-Perform ultrasound scan:
If not placenta praevia
-Keep in hospital for observation.
-If bleeding stops, discharge 24 hrs. after bleeding has stopped
- Advise not to have sexual intercourse for two weeks
-Advise to return immediately if recurrence
-Await spontaneous labour.
If bleeding continues but not severe:
-Keep in hospital/waiting shelter until 37 weeks
-Watch fetal growth
-Induce labour at 37 weeks
If placenta praevia – Gestational age 37 weeks or more
>Major placenta praevia (covers internal os) or grade 2b-perform caesarean section
>Minor; grade 1, 2a and bleeding is minimal-induce labour if cervix favourable or await spontaneous labour if cervix not favourable
Gestational age less than 37 weeks
-Keep in the hospital until bleeding has stopped, and then can be managed as an outpatient
-Repeat scan at 32- 34 weeks and again later before planning definitive mode of delivery.
-While in hospital:>daily pad checks ,daily fetal movement chart and fetal heart monitoring.
-weekly haemoglobin and keep 2 units of blood cross matched and available
Breech presentation is associated with higher incidences of congenital anomalies (6%), preterm birth, fetal trauma (fractures, brachial plexus, visceral injury e.g.liver, brain-hypoxic, maternal trauma, low APGAR scores compared to vertex presentation regardless of mode of delivery.
There is a higher risk of cord prolapse (15% with footling breech, 5% flexed breech compared to <1% with a frank breech or vertex presentation).
1.Frank/ Extended-flexed hips and extended knees
2.Complete/Flexed-flexion at both hips and knees
3.Incomplete/Footling-extension of one or both hip
Mode of delivery depends on the experience of the birth attendant and the patient’s wishes.
The options are:
-Planned / Elective Caeserean-section, or
-External Cephalic Version(ECV) of the breech to achieve cephalic birth
-Planned trial of assisted breech vaginal birth.
-Elective/planned Caeserean-section is the safest way to deliver a term singleton breech presentation
Mode of Delivery of a singleton term breech
As many breech presentations will become cephalic as pregnancy advances there is no need for action until 36 weeks.At 36 weeks consider the following:
-Ultrasound scan is performed to localize the placenta and exclude severe congenital malformation and estimate fetal weight.
-If there are no contraindications, perform Extrenal Cephalic Version(ECV).
-Absolute contraindications to ECV include>Previous caesarean section scar, Antepartum Hemorrhage, Placenta praevia, Severe proteinuric hypertension, Premature Preterm Rupture Of Membrane with oligohydramnios, and Severe congenital malformation.
-If ECV fails or it is contraindicated then decide on the mode of delivery
Perform caesarean section if
>Previous caesarean section
>Previous bad obstetric outcome, death of term baby
>Associated obstetric problem, Suspected feto - pelvic disproportion; (note that if previously she has delivered a normal size baby, pelvis is probably adequate)
>Estimated fetal weight more than 3.5kg and Footling breech presentation.
Management in labour:
If vaginal birth is the preferred route, labor augmentation and 2nd stage >60 minutes are associated with poorer outcomes.
If a decision has not been made on the mode of delivery, inform Registrar or consultant so that the decision can be made while the woman is in admission room.
-Set up an iv line to keep vein open.
-Keep prepared for possible caesarean section.
-During every vaginal examination feel for possible cord prolapse or presentation.
-Do not do Artificial Rupture of Membranes until in advanced labour.
-Perform vaginal examination immediately after membranes have ruptured to exclude cord prolapse and to assess cervical dilation and level of presenting part.
-Assess fetal heart rate carefully during labour.
-Avoid premature pushing; No pushing should occur until the buttocks are distending the perineum. Adequate analgesia should be given. If she starts to push before cervix is fully dilated give intravenous pethidine 75mg and have naloxone ready for baby.
-Assess progress of labour every two hours in active phase- THIS INCLUDES RATE OF CERVICAL DILATATION AS WELL AS DESCENT OF THE BREECH.
-Oxytocin may be used if contractions are weak but consultant should make this decision.
ALWAYS BE PREPARED TO DO CAESAREAN SECTION IF PROGRESS IS NOT SATISFACTORY – DO NOT ALLOW PROGRESS OF LABOUR TO GO TO THE RIGHT OF THE ACTION LINE.
Assisted Breech Delivery
-Most of the baby is delivered by maternal effort and the attendant delivers the head.
-Put patient in lithotomy position with poles, swab and drape vulva with sterile towels.
-Initially use “hands off” policy i.e. do NOT pull down breech that is still high.
-Also avoid spontaneous vaginal delivery because if delivery of the head is uncontrolled there is risk of injury to the brain.
-Infiltrate the perineum in case episiotomy is required. Elective episiotomy is not required especially in multiparous women.
Even in the second stage be prepared to do caesarean section if there is no descent of the breech.
-The woman is allowed to push with each contraction and the buttocks are delivered spontaneously.
-If the legs are flexed they will fall out but if they are extended apply pressure in the popliteal fossa and grasp the ankle and sweep the foot down and out. Similarly deliver the other leg.
-Ensure the fetal back is uppermost. If it turns downwards the chin will catch under the symphysis pubis and cause difficulty in delivery of the head
-If the arms are across the chest they will deliver spontaneously. As the anterior shoulder blade appears, place two fingers of the appropriate hand (right hand for right shoulder) over the clavicle around the shoulder and down the humerous to the forearm to bring it down.
-Grab ankles and swing upwards to deliver the other arm similarly.
Allow the body to hang until hairline is visible and then deliver the head using any of these methods:
The breech is grasped by the foot and pulled down to deliver the body up to shoulders as opposed to spontaneous delivery of the breech up to the shoulders.
-Delivery of 2nd twin which maybe breech or transverse with intact membranes
-Intrauterine Fetal Demise with cervix fully dilated
There is insufficient evidence regarding outcomes by mode of delivery. Outcomes in premature breech infants are mainly related to prematurity ± fetal anomaly.
Breech 2nd Twin
Vaginal delivery of the 2nd non-vertex twin is a reasonable management option.
Total breech extraction is associated with shorter maternal stay and lower neonatal pulmonary disease, infection and hospital stay compared to cephalic version.
Malpresentations of the vertex
Mento-anterior position:expectant approach/allow labor to progress. Use augmentation sparingly.
Mento-posterior/transverse:if no rotation to mento-anterior position do Caesarean section
Note. Many anencephalic fetuses have a face presentation.
For term fetus, the mento-vertical diameter (13.5cm) will not pass through the birth canal: vaginal birth not possible unless fetus is pre-term, or flexes to vertex, or extends to face presentation. If brow presentation persistent, do Caesarean-section.
Shoulder presentation as in a transverse lie
-There is increased risk: of cord prolpse, for uterine rupture & difficulty of vaginal delivery.
-Diagnosis: Abdominal or vaginal exam and USS confirmation if available. ? Before term- await spontaneous version to cephalic
-At term perform ECV if no contraindications or do elective Caeserean-section at 39 weeks
Occurs 1 in 1000 deliveries but higher with prematurity, multiple gestations, polyhydramnios & CPD.
-A fetal extremity is presenting alongside the vertex or breech during vaginal exam
-A common complication is cord prolapse, so if possible do continuous electronic fetalheart rate monitoring.
-Determine whether the prolapsed fetal part is a hand or foot.
>Vertex +hand/upper extremity- gently reduce –aim for vaginal birth
>Vertex+ lower extremity-perform caesarian section
>Breech + lower extremity is a footling breech: do caesarian section
-Obstructed labor e.g. cephalopelvic disproportion/abnormal lie
-Previous uterine surgery: prior Caesarean-section, myomectomy, previous uterine perforation from evacuation of the uterus/dilatation and curratage.
-Grand multi-parity, especially, with use of oxytocin/prostaglandins/misoprostol.
Cardiac Disease In Pregnancy
Rheumatic heart disease is the most common heart disease.
Other types include congenital heart disease, hypertensive, thyroid disease and cardiomyopathy.
Dangers:cardiac failure, endocarditis, and cardiac arrhythmias.
Patients with pulmonary hypertension from whatever cause have a case specific maternal mortality rate of 30-50%. Termination of pregnancy for maternal interests should be offered to the woman .Anticoagulants are to be given to women at high risk of thromboembolism e.g. prosthetic heart valves
Risk factors for cardiac failure include:
>Fever or infection
>Physiological changes in pregnancy associated with increased blood volume.
-Aortic valve area <1.5 square cm
-Mitral valve area <2 square cm
-Ejection fraction <40%
-Peak left ventricular outflow gradient > 30mmHg
-Extra rest is essential AND do not allow to gain too much weight
-Prevent anaemia- prophylactic iron and folate
-Admit to hospital 2-4 weeks before planned delivery
-Most go into labour spontaneously
Ensure emergency trolley is by the bedside. Trolley must contain oxygen, morphine, aminophylline, digoxin, frusemide and ETT with Ambu bag.
-Nurse in semi sitting position
Give adequate analgesia ( Morphine 5mg every 4 hours i.m or 10 mg every 4 hours orally) or pethidine hydrochloride 50-100mg i.m every 3-4 hours.
-Watch pulse, respiratory rate and blood pressure every 15 minutes
-Keep accurate fluid balance to ensure no fluid overload with risk of cardiac failure
-Antibiotic prophylaxis- Ampicillin 500mg iv stat and 6 hourly for 6 doses and Gentamycin 80mg im stat and 8 hourly for three further doses.
-If augmentation is required this decision should be made by a senior member. Use high concentration of oxytocin (150 ml bag.)
-Oxytocin may be used with or without Frusemide
-Nurse in semi-recumbent position
-Avoid aorto-caval compression
-Shorten the second stage of labour- forceps or vacuum
-Avoid raising legs into lithotomy position
-Avoid ergometrine in the third stage of labour
-Avoid beta-sympathomimetic drugs which cause tachycardia and vasodilatation
-Deliver in semi sitting position with legs hanging over the edge of the bed.
-When there is urge to push let patient give short pushes with mouth open
-If severe cardiac failure assist with vacuum.
-Do not use ergometrine with anterior shoulder because of risk of cardiac failure, give 5u oxytocin (im) to prevent PPH
-If patient has been unstable previously give 20-40mg frusemide iv immediately after delivery.
-Sedate and allow to rest
-Close observation of pulse, respiratory rate and blood pressure in Early Labour Ward.
-Give family planning advice before discharge
-Breast feeding is not discouraged
-Pulmonary oedema is a medical emergency that should be anticipated- nurse in semi sitting position, clear airways and give oxygen, intravenous aminophylline, morphine, frusemide and digoxin
-Peripartum cardiomyopathy should be suspected in a woman with acute dyspnoea and tachypnoea and tachycardia
-Use of ACE inhibitors is safe during breastfeeding
>Intrauterine growth restriction
>Fetal congenital malformations
Diabetes in Pregnancy
Risk factors for diabetes:
>Family history of diabetes
>Previous large babies
>History of diabetes in previous pregnancy
>Previous unexplained stillbirth or neonatal death
>Previous congenitally abnormal baby
>Glycosuria on two occasions
>Recurrent candidiasis or Urinary Tract Iinfections
Maternal: keto-acidosis, infections (candidiasis and urinary tract infection) retinopathy, nephropathy, pre-eclampsia, and polyhydramnios.
Fetal:congenital malformations, preterm, macrosomia, IUGR, intraurine fetal death, and birth trauma.
Neonatal:hypothermia, hypoglycaemia, hypocalcaemia, infections, hyperbilirubinaemia and polycythaemia.
Pre conceptual care:
-Use of contraception is advised until good glyceamic control is achieved as assessed by HbA1c levels< 6.1%
-Assess for diabetic retinopathy and nephropathy before pregnancy
-Folic acid supplementation 5mg/day until 12 weeks of gestation to reduce the risk of fetal neural tube defects
-Women at risk of diabetes e.g. obese, should be counseled about weight loss, diet and exercise prior to conception
-Women with diabetes should be advised on the importance of glycaemic control before and during pregnancy to reduce the risk of miscarriage, congenital malformations, still birth and neonatal death.
-Angiotensin converting enzyme inhibitors, Angiotensin II receptor antagonists and statins should be discontinued before conception or as soon as pregnancy is confirmed.
Care during pregnancy:
1. Diabetic control:diet and insulin (short & medium acting) or oral hypoglycaemics. Good control of blood sugar crucial-may need to admit frequently into hospital. Avoid hypoglycaemia. Aim at keeping sugars 3.5-6.0 mmoles/l as this is associated with optimal outcome for mother and baby.
2. Assess fetal growth: macrosomia as well as IUGR; scan at booking and at 28, 32, 36 weeks and assess fetal well-being from 32 weeks by daily kick chart and once or twice weekly CTG.
Obstetric care: see frequently – every two weeks until 36weeks, then weekly until delivery .Carefully observe blood pressure.
If diabetes is well controlled, induce labour after 38 weeks and deliver vaginally if there are no obstetric contraindications.
If inducing labour: starve from midnight, measure fasting blood sugar at 0600hrs give half her morning dose as soluble insulin and start 5% dextrose infusion and hourly insulin on a sliding scale checking blood glucose hourly (using dextrostix) and maintaining level between 4-7 mmoles/l.
-give oxytocin via separate saline litre
-during labour monitor fetal heart rate
-at delivery be aware that shoulder dystocia may occur.
-Intrapartum strict glycaemic control should be maintained.
-Hourly glucose checks are to be done and levels to be kept between 4-7mmol/L
-An infusion of insulin 50IU in 50mls saline, and 10mmol of KCL in 500ml of 5% dextrose can be given to maintain glycaemic control may be given as a continuous infusion.
If elective caesarean section:
Starve from midnight
Measure fasting blood sugar and urea and electrolytes at 0600hrs
Hypertension In Pregnancy and Ecclampsia
Hypertensive diseases of pregnancy are one of the major causes of maternal morbidity and mortality.
Classification of hypertensive diseases in pregnancy:
1.Pregnancy induced hypertension (PIH) also called gestational hypertension.
3. Chronic hypertension
4.Chronic hypertension with superimposed preeclampsia.
PIH is defined as a blood pressure of 140/90 mmHg or higher on two occasions, at least six hours apart, observed after 20 weeks of pregnancy and which resolves within 12 weeks post delivery.
Severe PIH is a diastolic blood pressure ≥ 110 mmHg or systolic blood pressure ≥ 160 mmHg confirmed by a repeat measurement after resting the patient for 10-20 minutes.
Is PIH with proteinuria (>0.3g in 24 hours). Urinalysis of ≥2+
Imminent eclampsia/Severe Preeclampsia:
Severe PIH with proteinuria in addition to symptoms such as headache, drowsiness, visual disturbance, epigastric pain, nausea or vomiting. There may be tenderness over liver with increased reflexes or clonus.
Is defined as the occurrence of one or more convulsions superimposed on preeclampsia. Development of eclampsia is not related to level of blood pressure alone. All women who have a convulsion during pregnancy should be managed as eclamptics until proven otherwise.
-Previous history of PIH, history of chronic hypertension or PIH in mother or sisters.
-Women over the age of 35yrs.
MANAGEMENT OF PIH and Preeclampsia
The disease is divided into mild, moderate and severe.
Mild PIH- systolic: blood pressure 140-149 mm Hg and/or diastolic pressure 90-99 mm Hg with no protenuria.
Moderate PIH: Systolic blood pressure 150-160 mm Hg and/or diastolic pressure 100-109 with no proteinuria.
Severe PIH: systolic blood pressure 160 mm Hg or above and/or diastolic blood pressure 110 mm Hg or more.
Mild, moderate and severe preeclampsia is the above blood pressure readings with a +, ++, and +++ of proteinuria respectively.
Management during the antenatal period
Mild hypertension : Diastolic BP 90-99mmHg, no proteinuria
-Manage as outpatient
-Weekly antenatal visits
-Monitor for development of proteinuria
Moderate hypertension :Diastolic BP 100-109mmHg, no proteinuria
-Monitor BP 4hourly
-Monitor for development of proteinuria
-Start on antihypertensives
-Consider methyldopa initially
-It may be necessary to add nifedipine or prazosin if BP readings remain high
-Assess foetal well-being
-Plan for delivery after 37 weeks
Severe hypertension : Diastolic BP ≥110, No proteinuria
-Monitor BP 4hourly
-Monitor for development of proteinuria
-Assess foetal well-being
-Start on antihypertensives as for moderate hypertension
-Add Nifedipine 10mg po stat for DBP ≥110
-Aim to deliver at term but earlier delivery may be indicated if there are foetal or maternal complications
Severity of Preeclampsia
The differentiation between mild and severe preeclampsia can be misleading because mild disease may progress rapidly to severe disease.
Management of severe preeclampsia
-Manage as inpatient
Management in Labour
ECLAMPSIA AND IMMINENT ECLAMPSIA
When a woman is admitted with a convulsion think also of other causes of convulsions:
Magnesium sulphate regime
NOTE: A combination of diazepam and magnesium sulphate can be fatal as they are both CNS suppressants.
Note: if there are repeated seizures alternative agents such as diazepam or phenytoin may be used but only as single doses. If convulsions persist consider intubation to protect the airway and maintain oxygenation and transfer to a facility with ICU.
Other points of management
Perform caesarean section if:
7.Intrauterine Fetal Death
It is essential that a cause be determined whenever possible for advice in future pregnancy.
Possible causes include:
Maternal causes – diabetes, hypertension, infections like syphilis, malaria and CMV and placental abruption.
Fetal causes- malformations, cord complications and severe IUGR.
Diagnosis must be confirmed by ultrasound scan except when associated with severe APH.
-Counselling and emotional support is crucial to help with grief and for future pregnancies.
-Discuss value of post-mortem.
-Investigations include VDRL/TPHA,FBC, glucose load test, antinuclear factor, Rh group.
-If IUD has been long standing (3-4 weeks) check platelet count and if this is low do a coagulation screen.
-Medical treatment with misoprostol
-Might need to admit if necessary
-800µg vaginal /600µg Oral
-Monitor for bleeding
-If no explulsion of RPOC or bleeding can repeat dose in 12hrs
-Analgesia should be given once contractions start
IF EXPULSION IS NOT COMPLETE TO BE COMPLETED WITH EVAC/MVA
Induce labour- this is USUALLY done as soon as diagnosis is confirmed. There are several ways of inducing labour.
Dose depends on gestational age
Vaginal 200µ 6-12hrly for 4doses. If first dose does not lead to effective contractions then next dose 400µg. Maximum daily dose 1600µg.
Vaginal 100µg 6-12hrly for 4doses. If first dose fails then next dose should be 200µg. Maximum daily dose is 800µg.
If cervix not ripe(B
At this gestation, before repeat misoprostol is given, assessment of uterine contractions SHOULD be done and if 2 or more contractions are palpated in 10min then the dose should not be repeated. If there is need to augment labour this should not be done within 6hr.
Use of misoprostol in the presence of uterine scar is discouraged and should be done on the advice of a consultant. The lowest doses are preferred.
Use misoprostol with caution in women who are more than para 3.Induction with extra amniotic saline infusion or by use of the traction catheter are the preferred modes of induction.
Extra amniotic saline infusion
-Insert intracervical catheter as for traction catheter.
-Inflate balloon with 20 mls water and apply slight traction and strap catheter to midthigh.
-Attach 1 l
-Explain to the patient that she will feel wet as the saline will escape through the cervix and that she must stay in bed while the drip is running.
-Send her to LW as soon as contractions are established.
Pessaries/ vaginal tablets as for induction.
Prostaglandin PGF 2α extra amniotic gel is not reaily available
Traction catheter followed by oxytocin as soon as catheter falls out
Management in labour:
-Delay ARM until in established labour, give oxytocin if progress slow
-Give adequate analgesia and commence on amoxicillin 500mg T.D.S and metronidazole 400MG t.d.s per oral
-Show the baby to the mother if she wishes to see after cleaning and draping. It is good practice to encourage mothers to see the baby.
-Examine foetus for congenital malformation with post mortem if possible
-Suppress lactation- firm breast support (not just a bra), do not express. Bromocriptine (2.5 mg twice daily for 10-14 days) may be used if no response to above.
-Organise post natal follow-up to discuss results and give advice on future pregnancies.
8.Induction of Labour
The clinical requirement for induction of labour arises from circumstances in which it is believed that the outcome of the pregnancy will be better if it is artificially interrupted rather than being left to follow its natural course. Below are some of the indications for induction of labour.
-Preterm prelabour rupture of membranes
-Term prelabour rupture of membranes
-Intrauterine fetal death
-Maternal request for induction
Prior to every induction
-Confirm the indication
-Explain the benefits and risks of induction and ? Get written or verbal consent.
-In case of failed induction ensure caesarean section is an acceptable mode of delivery. ? Examine the abdomen for:Height of fundus, presentation, lie, descent, fetal Heart. If available perform a non-stress test.
-Assess the cervix to get bishop score.
Risks of induction
-Hypertonic uterine contractions leading to fetal distress or uterine rupture
Methods of induction
Bishop score is greater than or equal to six.
-Amniotomy plus oxytocin
Bishop score less than six
Oxytocin and amniotomy
-At 0800 hrs assess cervical score and if the score is 6 or more perform ARM and commence oxytocin infusion.
-Start with low dose initially and gradually increase to produce effective contractions. The aim is to have at least 3 contractions in ten minutes.
-Generally for primigravida start with 4 units in 1 L Ringers Lactate at 10, 20, 40 drops per min. With multiparous women start with 1 unit and increase to 4. Increase dose every 30 mins and aim to get strong contractions within 4 hrs of commencement.
-Decrease the infusion rate as soon as contractions are strong.
-Side effects of oxytocin include hyperstimulation and water intoxication.
-Insert size 18 or above Foleys catheter through cervix, fill balloon with 40 to 80mls of water for injection and then pull and strap the end of the catheter down to mid leg and not thigh. Ask the woman to keep her leg straight until the catheter falls out. When properly done, the catheter usually comes off within a few hours.
-Oxytocin can then be put up immediately after the catheter falls out with or without ARM
Extra-amniotic Prostaglandin gel
-Pass a size 18 Foley catheter through the cervix as above. Inflate balloon with 30 mls water and knot the distal end. Inject gel into catheter (20mls) and flush all gel in tube with 10mls of air.
Prostaglandin E2 vaginal tablets
-One 3 mg or three 0.5 mg tablets can be inserted into the posterior fornix every 8 hours.
Extraamniotic saline infusion
-As described for IUD, can also be used for induction of labour for live foetuses.
This is a prostaglandin E1 derivative. It is effective as an induction agent given both orally or vaginally. Currently available preparations are 100 microgram and 200 microgram oral tablets which must be cut or made into suspension to achieve lower doses, but uniform concentration and accurate drug delivery is not guaranteed
-Both the vaginal and oral doses are effective and a single dose should not exceed 50ug
-50mcg or quarter tablet swallowed with some water. This can be repeated after 4hrs up to a maximum of four doses
-A 200mcg tablet dissolved in 200mls of water and stirred into a uniform suspension. 20mls of this suspension is then taken every 2 hours up to a maximum dose of 200mcg
-50mcg or quarter tablet inserted into the posterior fornix vaginally. This can be repeated after every six hours up to a maximum of four doses.
NOTE: Always assess the cervix and uterine contractions before the next dose. If the cervix is 3cm or more and there are no contractions ARM can be done and oxytocin put up.
Contraindications to Misoprostol
Use with caution in:
-Suspected macrosomia ? Para 3 and above.
-Multiple pregnancy o In this case, use 25 ml of the solution (200mcg in 200ml) every 4 hours
-If labour has not occurred within 24 hours , review all parameters, including cervical ripening before repeating cytotec
-Consider ARM +/- use of oxytocin at least6 hours after the last dose of Misoprostol
Always think of twins if there is a family history or previous history, uterus feels larger than gestational age by dates, palpation is difficult or there is polyhydramnios. Often three or more poles or multiple fetal parts are palpable.
-Urinary tract infection
-Pregnancy induced hypertension
-Antepartum haemorrhage (placental abruption and placenta praevia)
-Preterm labour and prelabour rupture of membranes, ? Polyhydramnios and malpresentations
-Watch haemoglobin- advise on good diet and start on iron and folate supplementation ? Encourage extra rest periods and less heavy work.
-Watch urine for protein
-Watch blood pressure every two weeks up to 28 weeks and then weekly
-Ultrasound scan in the first trimester to confirm gestational age and chorionicity
-Watch growth of babies carefully preferably by scan at 28, 32-34, 36-38 weeks; this is especially so for monozygotic twins.
-Watch for fetal wellbeing from 36 weeks, preferably weekly ? Plan mode of delivery
>Assess stage of labour
>Perform vaginal examination to assess presentation and exclude cord prolapse/presentation
>Labour is managed according to the presentation of the first twin o If transverse, caesarean section
Delivery of the first twin is usually uncomplicated but conduct delivery in lithotomy position and Registrar should be nearby.
>After delivery of the first twin, ensure cord is well clamped because if twins are uniovular the unborn baby might bleed if the cord were not firmly clamped
>Perform abdominal examination to confirm presentation of second twin
>Listen to the fetal heart
>Aim to deliver the second twin within 30 minutes o If transverse or breech attempt to perform ECV if membranes are intact o If ECV fails, perform internal podalic version i.e grab foot and gently pull down and rupture membranes and perform breech extraction
>If cephalic, perform ARM, add oxytocin to stimulate contractions and:
-Conduct delivery in the usual way o Maximum interval between deliveries should not be more than 30 minutes.
Transverse lie of the second twin
If the uterus has clamped down onto the baby after rupture of membranes one may need to perform caesarean section. If membranes are intact perform internal podalic version and breech extraction.
Delay in birth of second twin
If uterine contractions are poor or do not resume within 20 minutes of delivery of the first twin, start-up oxytocin infusion. This should have been avoided by having oxytocin infusion ready just before delivery of the first twin.
Expedite delivery by vacuum extraction or caesarean section
Maternal haemorrhage before birth of second twin
-If binovular, placenta of the first twin separates and may deliver before delivery of the second twin. This is a warning that placenta of the second twin may also be starting to separate and will cause hypoxia of the second twin. Rupture membranes and deliver second twin as soon as possible.
-Ergometrine or syntometrine might have been given already and the resulting contraction may cause anoxia. Uterine rupture may also occur. Immediate delivery is needed- caesarean section may be required.
-Prevent post-partum haemorrhage: give iv ergometrine or oxytocin if hypertensive and put 20 units oxytocin/litre as slow iv infusion.
Demise of one twin is an indication for immediate referral to a tertiary institution
10.Post Term Pregnancy
Definition: pregnancy lasting 42 completed weeks or more
A carefully obtained history is the cornerstone of appropriate management. Detailed information on menstrual pattern and the accuracy of the dates of the last normal period are important. Use of hormonal contraception, abortion, or lactation immediately preceding the pregnancy should be obtained accurately at the first booking visit. This will be the basis of deciding on whether dates are certain or not.
If the midwife saw her before 24 weeks, correlation between gestation by dates and by palpation would be useful. If she had an early scan this will help confirm dates.
-Re-evaluate menstrual history
-Assess cervix (Bishop’s score) for possibility of successful induction o If cervix is favourable labour can be induced (see induction of labour) o If cervix unfavourable, admit to ripen the cervix and induce only when cervix unfavourable.
-NST twice weekly if waiting for more than a few days.
-Aim to deliver between 41 and 42 weeks.
Onset of Labour before 37completed weeks of gestation.
If duration of pregnancy is unknown, the diagnosis is made on account of EFW of <2500g. Risks of complications are low if EGA >34weeks.
In a patient with preterm labour ,regular & usually painful uterine contractions are observed at least 2 in 10 minutes with or without history of rupture of membranes +/- cervical effacement and/or dilatation without a history of rupture of membranes
-Maternal or fetal tachycardia,
-Uterine tenderness and
-Foul smelling liquor
-No signs of chorioamnionitis are present
-Diagnosis made by culture or histologically
>Maternal Pyrexial illness e.g. Malaria,Acute Pelonephritis
>Congenital Uterine abnormalities e.g. bicornuate uterus,uterine fibroids
-Congenital fetal abnormalities e.g neural tube defects, gastrointestinal defects, tracheoesophageal fistula
High risk patients for Preterm Labour
-Previous preterm labour
-History of early pregnancy bleed or draining liquor
-Poor socioeconomic status
-Smoking, alcohol and habit forming drugs.
Management of Preterm Labour
-Determine the duration of pregnancy as accurate as possible
-Listen to fetal heart.
-Duration of 34-36 weeks : Allow labour to continue
-Duration of 28-33 weeks :
-Nifedipine 30mg orally then 20mg 8 hourly OR
-Indomethacin 100mg rectally 12 hourly(up to 32weeks) OR
-Nebulisation with Salbutamol OR
CONTRAINDICATIONS TO TOCOLYSIS
-Pregnancy duration >34weeks or <24weeks.
-Intrauterine fetal death
-Congenital fetal abnormalities incompatible with life
-Serious intrauterine growth restriction
-Preterm rapture of membranes.
-Best between 28 and 32 weeks of gestation) o -Betamethasone 12mg IMI 24hours apart OR o -Dexamethasone 12mg IMI 12hours apart.
Entonox is ideal method of pain relief (Avoid Pethidine as it suppresses newborn respiration).
12.Pre-term Rupture of Membranes
Pregnant woman <37 weeks of gestation, with a history of a sudden gush of a large volume of fluid vaginally, followed by continuous leakage of a small volume of watery fluid.
Confirmation of diagnosis
-Sterile speculum examination
-Visible drainage of liquor through the cervical os
-Liquor accumulates in the posterior blade of the speculum or in the posterior fornix
-Drainage can be demonstrated by asking the patient to cough
-Reduced risk of ascending infection
-Possibility of cord prolapse can be demonstrated
-Demonstrates cervical effacement and dilatation
-pH testing(pH>7 alkaline) or turns red litmus paper blue
NB: NO DIGITAL VAGINAL EXAMINATION. It has no value in determining the rupture of membranes and merely increases the risk of infection.
-If the patient is in labour; Allow the labour to progress , start antibiotics (Erythromycin 250mg qid orally)
Indications for immediate induction of labour (or Caesarean section):
-Pregnancy duration >34 weeks or <28 weeks
-Intrauterine fetal death
-Severe congenital fetal abnormalities
-Clinical signs of chorioamnionitis
-Other obstetrics complications e.g preeclampsia,diabetes
-Confirmed fetal lung maturity
-Pregnancy duration 28weeks to 34 weeks
-Admit for bed rest:NB NO DIGITAL VAGINAL EXAMINATION
-Monitor fetal wellbeing
-Symphysio-fundal height measurement
-Four hourly fetal heart monitoring
-Weekly Non Stress Test or Ultrasound scan
-Antibiotics(Erythromycin 250mg qid orally)
-Corticosteroids(Betamethasone 12mg IMI x2 doses
24hours apart or Dexamethasone 12,5mg x2 doses
-Continuous observation for possible signs of infection.
-Maternal pulse rate ,temperature and fetal heart rate 4hourly
-Twice daily abdominal palpation to detect uterine tenderness
-Pad/Contraction checks and observation for possible offensive smell of the liquor
-Full blood count
-Pregnancy is allowed to continue until complications develop e.g chorioamnionitis, fetal distress, labour starts spontaneously or gestation reaches 34 weeks.
-If draining totally ceases, the pregnancy is allowed to continue until she goes into spontaneous labour
-Patient is discharged from hospital if there is no draining for at least 48hours
-Patient must be reviewed weekly until 34 weeks gestation.
Prelabour Rupture of Membranes
-Rupture of membranes after 37 weeks of gestation ,which is not followed by labour within one hour.
-If not complicated by infection ,wait for 48hours before induction of labour. Cervix becomes more favourable, which increases the chances of successful induction.
-Induction should be initiated at a more practical and convenient time of the day.
-During this waiting period 80% of patients will go into spontaneous labour.
-If complicated by chorioamnionitis, induce labour immediately or perform caesarean section.
Decision on mode of delivery must be made at the antenatal clinic by a Registrar / Consultant by 36 weeks. In making a decision, take into account obstetric outcome in previous pregnancy as well as complications in the index pregnancy. If there is obvious CPD, breech presentation and other malpresentations ,multiple pregnancy or previous upper segment caesarean section in a woman with one previous Caesarean section, vaginal delivery is contraindicated. If the decision has not been made at the antenatal clinic please consult Registrar on admission in labour.
For all women who have had a myomectomy, perform elective LSCS, unless there is information available that the myomectomy did not breach the endometrial cavity.
Management in labour:
-Put up an iv canula to keep vein open
-Send blood for Hb and group and retain serum
-Monitor fetal heart, maternal pulse and blood pressure carefully
-Perform vaginal examination every two hours and observe for fresh bleeding
-Monitor progress of labour- expect to be to the left of the action line
-Oxytocin is generally only used to initiate contractions but not to augment contractions that are strong but thought to be in coordinate.
-Decision to use oxytocin should be made by Consultant
-After delivery observe in ELW for vaginal bleeding. Exploration of uterine scar is not routinely performed after delivery unless there is excessive bleeding or one suspects uterine rupture.
14.HIV in Pregnancy
The prevalence of HIV in Zimbabwe is 13.8. National Prevention of Mother to Child Transmission (PMTCT) guidelines are modified from regularly revised WHO guidelines.
Based on current evidence 2 groups can be defined based on CD4 cell counts:
≥ 350 cells/ml - patients not yet in need of HAART for their own health;
<350 cells/ml - patients should be initiated and continued on HAART.
-HIV vertical transmission to the foetus and infant of about 30% if there is no intervention
-Increased Maternal, Neonatal and Infant mortality (MMR.NMR,IMR)
-Increased maternal morbidity - anaemia, sepsis, opportunistic infections, HIV-related comorbidities
-Increased foetal and neonatal morbidities- IUGR, Preterm deliveries and associated complications, Stillbirths.
Ideally couples should know their HIV status before conception but all women should be offered HIV TESTING (Provider Initiated) at their booking visit or at first presentation even if this is at the time of delivery.
HIV positive women should have a CD4 count done to decide on PMTCT strategy.
ANTIRETROVIRAL THERAPY and PROPHYLAXIS
-CD4≥350 cells/ml -Daily AZT for the mother beginning 14 weeks gestation till delivery
-CD4≤350 cells/ml -HAART plus Cotrimoxazole prophylaxis throughout pregnancy and breast feeding.
Obstetric factors that increase the risk for MTC transmission
-Amniocentesis and amnioscopy
-Premature rupture of membranes and Preterm labour
-Sexually transmitted infections during pregnancy
-Malaria in pregnancy
-Treatment of anaemia with haematinics
-Screening and treatment of STI and lower genital tract infections such as syphilis, candidiasis, trichomoniasis, Bacterial vaginosis
-Close monitoring for IUGR
-Avoidance of invasive obstetric procedures( eg amniocentesis, external cephalic version)
-Nutritional counselling and supplementation
-Universal Precautions since not all parturients have known HIV status:
-Eye protection during pelvic assessment and delivery procedures
-Delay amniotomy till at least 6cm dilatation
-Avoid invasive monitoring( foetal scalp electrodes, foetal blood sampling)
-Avoid instrumental delivery unless absolutely necessary to safeguard the foetus
Labour and Delivery
Mothers with CD4 counts ≤350 cell/ml should be on HAART.
Mothers with CD4>350cell/ml:
MOTHER: Single dose Nevirapine 200mg at onset of labour
-For mothers who do not need ARV for their own health, breast feeding infants should receive Nevirapine daily in increasing weight-based doses from birth until one week after exposure to all breast milk has ended.
-In non breast feeding infants, daily administration of AZT or Nevirapine from birth until
For all HIV positive mothers DUAL contraception of an effective hormonal or non hormonal method
Details on different PMTCT scenarios and how to manage them can be obtained from the National PMTCT guidelines document which is updated regularly.
15.Labour and Partograph
When the woman arrives you must decide whether she is in labour or not. Usually she will have regular painful uterine contractions, 3 in 10 mins with a show or ruptured membranes and associated cervical changes.
Management of labour in latent phase:
Start a partograph for every patient admitted in labour with zero time being time of admission.
Progress of labour
Cervical effacement is the assessment of the length of the cervical canal as length in cms and not percentage.
Cervical dilation is plotted as an “X” on the partograph.
The strength of contractions is graded as: mild or weak (<20 sec)/ moderate or fairly strong (20-40sec) and/ strong (>40 sec).
Draw in the ALERT LINE AND ACTION LINE if not already done.
Progress of labour must be assessed every FOUR hours if uncomplicated and every two hours if there are problems or labour has crossed the alert line.
Remember that there may be satisfactory cervical dilation with increasing caput and moulding and no descent of the presenting part- this may be an indication of cephalo- pelvic disproportion (CPD).
Mark the position of the head with reference to the posterior fontanelle or position of the breech with reference to the sacrum.
Sign legibly every vaginal examination and mark on the partograph the time for the next VE. Also indicate whether that VE should be by midwife or doctor.
Monitor maternal condition
Watch pulse, BP, temperature and urine.
Monitor fetal condition
Fetal heart rate: record fetal rate every half hour and more frequently if abnormal.
Liquor: if the membranes are intact write “I” in the appropriate column, if membranes have ruptured and the liquor is clear write “C”, if the liquor is meconium stained write “M”
Moulding: both occipito-parietal and parieto-parietal moulding should be recorded each time a vaginal examination is performed. Record as +, ++ or +++.
Caput: this is also noted each time a VE is performed and recorded as +, ++ or +++.
Poor progress of labour (prolonged labour) in active stage:
Commence antibiotics if membranes have been ruptured for more than 12 hours.
Ensure adequate hydration- put up a litre of Ringers lactate.
ARM if this has not been performed.
Empty bladder if full.
Assess the cause of the poor progress and manage accordingly:
Inefficient uterine contractions:
Unless there is obvious CPD, always assume this is the primary cause. Contractions may be weak and short lasting or may feel strong but are ineffective (incoordinate contractions), typically seen in primigravida.
If there are no contraindications start Oxytocin infusion, give adequate analgesia, and review progress 2 hourly.
Use the low dose oxytocin (1-4iu)
Malposition of the head:
Occipito posterior position:
This is the commonest cause of prolonged labour especially in primigravida.
Stimulate contractions to encourage rotation into occipito anterior position for delivery to occur in occupito-posterior position or face to pubis.
Give pethidine to avoid pushing before full dilatation.
There is no evidence of CPD but the cervix fails to dilate despite good contractions and trial use of oxytocin.
Deliver by caesarean section:
Management of second stage of labour
Listen to the fetal heart after every second contraction.
Duration of the second stage is timed from when the patient starts pushing and must be noted.
Second stage should not last more than 30 mins in primigravida and more than 20 mins in multigravida.
Active Management of the Third Stage of Labour
This consists of
Perform caesarean section if:
-CPD: head 2/5 th above brim with 3+ of moulding or 3/5 the above with any moulding.
-Brow or mento posterior face,
-Severe fetal distress
Perform Vacuum delivery if:
16.Analgesia in Labour
Antenatal education is a vital part of preparing women for the pain of labour. Less medication is used if patient prepared psychologically for childbirth experience. Always individualize patient treatment. Know the pharmacology of the drug you intend to administer i.e. limitations, dangers, contraindications & advantages. All analgesics given to the mother will cross the placenta.
METHODS Non-medical/Psychological/ Natural Childbirth
Systemic pharmacologic intervention
Either narcotics or sedatives with anti-emetic (prochlorperazine/stemetil12.5mg or promethazine/phenergan 25mg) during the 1st stage of labour relax patients & decrease pain. eg. Pethidine (1-2mg/kg body weight
Antidote to opiates: Naloxone 0.01mg/kg I.M.
Entonox is an equal mixture of nitrous oxide and oxygen (50% N2O and 50% Oxygen). It is used for pain relief for late1st & 2nd stages of labour, crowning of the head, ARM and during initiation of epidural analgesia.
Administration: The patient needs to breathe in as soon as she feels a contraction is starting and take two to three puffs with each contraction. It is good in early labour and during the latter part of first stage labour
This is the most ideal analgesic in labour but should be used only when there is adequate nursing staff to monitor the woman and fetal heart rate, facilities for cardio-pulmonary resuscitation and oxygen & suction should be immediately be available. Its main indication is effective pain relief in labour, e.g. in dysfunctional labour, hypertension, multiple pregnancy, instrumental/assisted vaginal breech births.
Potential Problems with Epidural Analgesia
? Prolonged labour if block too extensive. Treatment is by oxytocin infusion.
Pudendal Nerve block: Local anaesthetic injected bilaterally as it passes just medial to the ischial spine. It is used for pain relief during the
Consent for minors/ vulnerable women/ mentally incapacitated women
Please take time to explain to the woman why she needs an operation and what that exactly means. Include all the probable outcomes and side effects of the procedure and implications for future pregnancy. Informed consent is important particularly in subsequent pregnancy care. Pregnant minors are allowed to give consent for all procedures including caesarean section and care for their newborn.
Cord presentation - umbilical cord lies in front of the presenting part with the membranes still intact.
Cord prolapse– as above but with membranes ruptured.
Suspect cord prolapse if fetal heart rate is abnormal for no apparent reason.
Fetal heart present:
Foetus heart absent:
Allow labour to continue and deliver vaginally.
We should rely on fetal heart rate patterns picked up with the Pinard stethoscope or CTG. If there is high risk of fetal distress (thick MSL, PIH, prolonged labour etc) assess fetal heart rate using the hand held Doppler or CTG if at all in doubt.
Fetal HR patterns that suggest fetal distress include:
This is aimed at intrauterine resuscitation followed by Delivery
Intrauterine resuscitation measures
Delivery (Definitive Management)
If HR returns to normal observe very carefully, keep patient on her side, prepare for caesarean section and discuss with registrar
Injury to Genital Tract During Delivery
After delivery of the baby and placenta, the vagina and perineum should be carefully inspected to determine if any injury has occurred during the delivery, especially if there is postpartum bleeding in the presence of a well contracted uterus. Adequate examination and repair of the upper vagina and cervix requires adequate light and equipment.
Meconium Staining of Liqour
Presence of meconium may be a sign of fetal distress. It is therefore important to detect this and be alert before the actual delivery. Presence of thick meconium staining of liquor is an indication for transfer of the patient from the Clinic to a referral Hospital.
A baby born in the presence of significant MSL should be observed for at least 12hrs for:
Progress of labour has been arrested by mechanical factors, usually cephalo- pelvic disproportion.
Shoulder dystocia is defined as failure of delivery of the shoulders after the delivery of the fetal head.
Factors associated with shoulder dystocia
The skilled birth attendant should routinely observe for the following signs which may indicate that there is shoulder dystocia:
This is an emergency and when called, the attendant must be able to go through the various stages to deliver the baby in an orderly manner without panicking. We have 5-7 minutes to deliver the baby to avoid serious damage. Care must be taken not to twist the neck and as far as possible avoid excessive traction on the head to avoid damage to the brachial plexus.
Second Line Manoeuvres
If these simple measures (the McRoberts’ manoeuvre and suprapubic pressure) fail, then internal manipulation will be applied. Apply the following internal procedures in order:
Before attempting a vacuum delivery:
DO NOT PERFORM EPISIOTOMY UNLESS IT IS ABSOLUTELY ESSENTIAL
These patients have a high risk of Post partum Hemorrhage and therefore give iv oxytocin after delivery
Resuscitation and Care of Newborn
As the baby’s head is crowning, get ready to support the perineum. As the head is born wipe out excess mucous but handle baby gently. Wait for the next contraction to deliver the body and lay the baby on to the mother’s abdomen and note time of birth.
If there was no meconium and the mucus is clear there should be no need for suctioning.
Most healthy babies will cry and breathe spontaneously at birth. Leave these babies alone unless there was meconium staining of the amniotic fluid.
Is the failure to initiate and sustain respiration at birth. This could be due to intrauterine hypoxia (eclampsia or after general anaesthesia, hypertension, haemorrhage, hypertonic uterine contractions) or from birth asphyxia (obstruction of the airway by mucus plug, blood or meconium) or from traumatic cerebral damage from a difficult delivery.
Although birth asphyxia may be anticipated there are times when the baby is born in an asphyxiated condition without any forewarning. Therefore resuscitation equipment must always be available and in working order and all attendants must be familiar with its use.
Warmth- hypothermia worsens hypoxia. Remove wet towels, cover body and head with pre warmed blanket leaving the chest exposed.
If the baby’s breathing is normal (30 – 60 breaths/minute) and there is no indreawing of the chest and no grunting
If there is no gasping or breathing at all after 20minutes of ventilation or gasping but no breathing after 30 minutes of ventilation, stop ventilating.
Note: Do not in any case
Naloxone – antidote for maternal narcotic drugs administration. It does not depress respiration itself and therefore does not do any harm. The dose is 100 micrograms per kg- neonatal naloxone 1-2mls; ie 0.5mls for every tiny baby, I ml for a small baby, 1.5mls for an average size baby and 2mls for a big baby. The dose can be repeated safely.
Post Partum Hemorhage(PPH)
Bleeding from the genital tract at any time following the birth of the baby up to 6 weeks after delivery. Post Partum Hemmorrhage is a major obstetric emergency contributing 25% maternal mortality in Zimbabwe.
IT IS THE EFFECT OF BLOOD LOSS RATHER THAN JUST THE AMOUNT OF BLOOD LOOS THAT MATTERS.
Call for help with blood loss over 500 mls even without systemic signs and also with blood loss of less than 500 mls if there is deterioration in the woman’s haemodynamic status.
Management- Placenta Delivered
Management- Placenta NOT delivered
Management- Traumatic PPH
Loss of a pregnancy before it reaches viability (WHO definition 22 weeks or 500g). At least 15% of confirmed pregnancies end up in miscarriage, mostly in the first 12 weeks.
Bartholin’s glands are bilateral mucus secreting structures situated at the opening of the vagina. They are usually not palpable. An abscess or cyst developing in the duct of the Bartholin’s gland is situated at the junction between the anterior 2/3 and the posterior 1/3 of the labia.
Clinically: presents with pain, redness, tenderness and fluctuation in addition to the vulval swelling.
Treatment: - is by drainage and marsupialisation of the abscess.
A Bartholin’s duct cyst is treated by marsupialisation. If the cyst recurs, it is usually best to remove the cyst and the gland. Marsupialisation
After local anaesthesia:-
This is a result of the fertilised ovum implanting outside the uterine cavity. The commonest site is the ampullary portion of the fallopian tube (~72%), followed by isthmic, fimbrial and cornual portions in that order.An ectopic pregnancy can also occur in the ovary, abdominal cavity or the cervix. Most will cause catastrophic intra-abdominal haemorrhage due to rupture of the fallopian tube, a significant cause of maternal mortality. Pelvic inflammatory disease is the commonest underlying cause of the associated tubal blockage.
Diagnosis of ruptured ectopic pregnancy This will be made based on the following:
Unruptured Ectopic Pregnancy:
NB: There are several case reports in literature where patients have ruptured following an examination
Manual Vacuum Aspiration(MVA)
The majority of women can tolerate the procedure of MVA without analgesia if given adequate explanation and support. MVA is a vital tool in reducing bed occupancy as the major burden of emergency gynaecology work comes from miscarriages. Cervical preparation can be very useful as it reduces the pain experienced in those requiring cervical dilatation.
What is MVA?
Indications for MVA:
For patients whose cervices are closed and/or require dilatation, administer Misoprostol 400/600mcg (3 tablets) into the posterior vaginal fornix at least 2 hours before the procedure.
It is often possible to perform MVA without any analgesia. If however you have an anxious patient, give 10mg diazepam half an hour before the procedure.
Cervical Block Techniques:
ii. Intra-cervical -10-20 mls of 0.5% or 1% Lignocaine
1. may choose to use 100mg pethidine and 10mg diazepam prior to the procedure.
Intra-operative prophylactic antibiotics:
This is usually adequate to prevent any post evacuation infectious morbidity. Give metronidazole 1gram PR or 2 grams orally post-procedure or intravenously during evacuation.
NB: Never push plunger in while it is attached to canula and the canula is in the uterus due to risk of embolism.
Answer any questions and rediscuss contraception. Please ensure that the patient leaves with some form of contraception if she has decided to use one. If she requests an injection or an implant make arrangements for her to get one. Sterilisation should also be booked there and then if she requests it.
Pelvic inflamatory Disease
infection of the genital tract infection above the level of the internal os.
Upper genital tract infection or PID is a common gynaecological emergency. It occurs both symptomatically and asymptomatically causing serious morbidity especially in young women. It is a significant public health concern as it is the commonest cause of tubal infertility and chronic pelvic pain.
A number of organisms are associated with development of PID. Often these are found within the cervix and vagina without any pathological consequences. Usually there will be some trigger that precipitates the pathological process such as sexual intercourse and uterine instrumentation.
The commonest organisms are:
Factors Influencing upper genital tract infection (introduction of organisms to the upper genital tract).
It is therefore prudent to consider screening for Chlamydia or offering universal prophylaxis for certain procedures mentioned above. Combined pill is protective.
Clinical Features of Early infection
Patients with acute PID present with a wide range of symptoms and signs that depend on their initial infecting organism.
Chronic Pelvic Inflammatory Disease
In cases where an IUCD is in-situ, there is evidence to show that removal improves outcome, though this should be considered if not better after 24-48 hours of antibiotic treatment. Arrangements should be made to reassess with 7 days.
If there is no improvement after 24-48 hours of IV antibiotics or if there is clinical suggestions of a pelvic mass, laparotomy is indicated
This is infection of the genital tract occurring at any time after delivery up to 42 days postpartum. It is a major cause of direct maternal death.
Predisposing factors include:
Signs and symptoms
Diagnosis is based on clinical findings:
Management of puerperal sepsis
Aggressive treatment is important. The patient should be admitted for investigations, intravenous therapy, and surgical management if indicated.
The patient should be commenced on broad spectrum, triple intravenous antibiotic therapy. Puerperal infection is commonly poly-microbial. Therapy is initially directed at most of the mixed flora that typically cause puerperal infections.
Antibiotics should be commenced at least 12hr before the procedure if possible
There are dedicated rape clinics at main teaching hospitals, where comprehensive services are offered for free. In Harare, the Adult Rape Clinic is situated at Mbuya Nehanda Maternity Hospital (Parirenyatwa).The Family Support Trust Clinic, which provides services for survivors aged 16 years and under, is situated at Harare Central Hospital.
In Bulawayo, both Mpilo Central and United Bulawayo Hospitals offer similar services at dedicated clinics. Outside normal working hours, survivors can be seen in Casualty Departments.
Survivors need to be attended to as soon as possible. If there are specific problems that the Registrar, Government Medical Officer and Sexual Assault Nurse Practitioner are unable to deal with, the case should be referred to a Consultant. Refer paediatric survivors to Paediatric Teams or see national guidelines on Management of Sexual Violence.
Principles of management
If a survivor is seen out of normal working hours and a senior is not immediately available to attend to her, the Seniour Resident Medical Officer can start to address time-sensitive issues such as HIV post-exposure prophylaxis and emergency contraception. Prophylactic antibiotics for sexually transmitted diseases, as well as any acute medical needs are also addressed at this point.
HIV Post-Exposure Prophylaxis (PEP)
Survivors should be offered pre-counselling and rapid testing for HIV infection. Those who present within 72 hours and test HIV-negative should be offered PEP as soon as possible.
Recommended PEP Regimen for Adults and Children >40kg
Combivir (AZT 300mg+Lamivudine150mg) 1tablet twice daily and Kaletra (Lopinavir 200mg +Ritonavir 50mg) 2 capsules twice daily x 28 days
NB: If Kaletra is not available, use combivir + efavirenz only
Emergency contraception should be offered to all female survivors who present within 5 days (except girls under 10 years of age and post-menopausal women)
Oral emergency contraception is most effective if given within 72 hours. It may be given between 72 and 120 hours with some effect.
Pregnancy Resulting From Rape
Prophylaxis for Sexually Transmitted Infections
Survivors who present late (eg several weeks or
If a survivor is seen in a sexual assault referral clinic, follow-up for continuing medical care and psychological support will be arranged at the time. If she is seen in Casualty, she should be referred to a sexual assault referral clinic as soon as possible for a follow-up management plan.
Cervical Cancer Screening
Cervical Cancer Screening
Invasive Cervical Cancer (ICC) is the most common cancer in Zimbabwean women occurring in 27 % of women diagnosed with cancer. Cervical cancer rarely occurs in women under 30 years with about 80% - 90 % as histologically confirmed squamous cell carcinoma and 10- 20% as adenocarcinomas.
The primary cause of cervical cancer is infection with one or more high risk types of the human papillomavirus (HPV) types 16, 18, 31, 32,33, 35, 45, 56,58). If HPV persists and results in development of precancer (CIN). If left untreated can lead to ICC in 10- 20 years for HIV negative women. Most cervical cancers can be prevented by early detection (screening) and treatment of precancerous lesions (CIN). In HIV infected women, progression of precancerous lesions to ICC is much faster, within 5- 7 years of acquisition of high risk HPV infection.
The Four Components of Cervical Cancer Control
A sample of cells is taken from the transformation zone (TZ) of the cervix with extended tip of wooden spatula or cytobrush, sample is smeared onto a glass slide and immediately fixed with an alcohol-based solution to preserve the cells. The slide is sent to cytology laboratory where it is stained and examined using a microscope to determine whether the cells are normal or abnormal. A satisfactory smear requires adequate number of well-preserved squamous epithelial cells and adequate endocervical cells. Sensitivity of conventional cytology can be 84% and specificity over 90%.
Visual Inspection with Acetic Acid (VIA) or (Visual Inspection with Lugose Iodine)VILI
Dilute acetic acid (3-5%) is applied to the cervix and after 2 minutes, abnormal cervical epithelium turns temporarily white (aceto-white) and this is test-positive (abnormal) or negative (normal) result if no aceto-white lesion is observed. If iodine is applied to cervix precancerous lesions appear well – defined, thick, saffron- yellow in colour, while normal squamous epithelium stains brown or black and columnar retains its normal pink colour. VIA/VILI do not rely on laboratory services, immediate treatment for test positive cases can be treated with cryotherapy or loop electro- surgical excision procedure (LEEP). VIA has sensitivity of about 77% (range 36- 94%) specificity of 86% (range 74- 94%).
HPV DNA test
A sample of cells is collected from the cervix or vagina using swab or small brush and placed in small container with preservative solution. Specimen is transported to laboratory that performs HPV DNA testing by PCR to detect high risk HPV.
HPV infection is very common among women <30 years. HPV DNA test, can be used together with cytology or VIA\ VILI because of its high sensitivity and low specificity.
Diagnosis and Treatment of Precancer Lessions
Management of Invasive Cervical Cancer
Women with advanced cervical cancer should be offered palliative care.
The goal of palliative care is to offer supportive care, symptom control, end –of- life care, and bereavement care to women with advanced ICC and her family.
WHO’s analgesic ladder starts by first step to give a non- opiod, typically paracetamol, if it does not relieve the pain then opiods (eg. Codeine) and the third step morphine for severe pain.