GUIDELINES FOR CAESAREAN SECTION

1. Introduction:
Caesarean section is the commonest major operation in Obstetrics. Prevelance
varies between 15-25% of all deliveries. This guidelines describe the
techniques of the operation and the managent of its complications.

2. Pre-operative preparation:
- Admit all patients 48 hours before surgery and obtain a written informed
consent.
- Take history and perform general and obstetrical examination; and identify
problems e.g. placenta previa, diabetes.
- Assess gestational age carefully (LMP, early or late U/S, fundal height).

- Uncomplicated patient:
o Do CBC, Urine, Blood sugar, HIV-Hepatitis antibodies screening,
blood grouping and cross-matching and prepare at least 2 pints of
blood.

- Complicated patients:
o (Diabetes mellitus, renal, hypertension, bronchial asthma, heart
disease, thyroid disease, sickle cell anaemia, placenta previa, DVT
etc)
o Do: CBC, Urine, Blood sugar, HIV-Hepatitis antibodies, blood
grouping and prepare 4-6 pints of blood.
o Assess condition of patient properly; and order relevant
investigations e.g. LFT, renal function tests, ECG, Echo, X-ray
chest, blood sugar. Consult physician and anaesthetist.

o Postpone operation for 1-2 days if her medical problem is not

controlled e.g. diabetic ketoacidosis, attack of acute bronchial
asthma.

Further preparations:
- Fasting over night or for at least 6 hours
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 - I.V fluids dextrose saline 125 ml/hour at 7 a.m.
- Clean the vagina in the operating room with Iodine (Yamidine)
- Catheterization in the theatre under aseptic conditions
- Check fetal heart
- Prophylactic antibiotics: third generation cephalosporin 1 g
intravenous half an hour before surgery an 1 g intravenous 12 hours
later.
OR: second generation cephalosporin I.V 1 g after clamping the cord.
OR: Ampiclox 2 g after clamping the cord
OR: Gentamycin 160 mg I.V+500mg metronidazole infusion ½ an
hour before surgery

- Anaesthesia:
Spinal anaesthesia is safer and more effective than general anaesthesia
- Check: Pulse, BP and respiratory rate before surgery.
- Left lateral tilt.
- Do PV examination in emergency C/S in labour, may be in advanced
second stage and could be delivered by forceps.
- Check fetal heart before surgey.

3. Technique:
1. Skin washing: Iodine (Yamidine)

2. The abdominal incision :

2.1. Pfannenstiel incision:
- Cosmetic appearance, low incidence of wound dehiscence and hernia
formation. It is not suitable for complicated cases (placenta previa,
obstructed labour).
- The skin and subcutaneous tissue are incised transversely slightly
curvilinear at the level of pubic hair (2 fingers above symphysis pubis
along the skin crease) and extended beyond the lateral borders of the
rectus muscle (approx length of incision 15 cm).
- The rectus sheath is opened by scalpel and extended by scissor, then
separated from the underlying rectus muscle superiorly (level of
umbilicus) and inferiorly by blunt dissection. Perforated blood vessels are
ligated.
- The rectus muscles are separated, the transversalis facia and peritoneum
are opened (scalpel or blunt) and peritoneal cavity and uterus exposed.
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 2.2. Midline vertical incision:
Extends from the pubic symphysis to within 2 cm of the umbilicus. Then
fascia is elevated and sharply dissected from pubis to umbilicus

- Traditional approach
- Indications
Previous midline vertical incision, Obesity, placenta
praevia, abnormal lie and emergency C/S.
- The incision extends from the pubic symphysis to within 2 cm
of the umbilicus
- The rectus sheath is incised with a scalpel and completed with
scissors.

- Then the recti are separated, transversals facia and peritoneum

are incised.

The operation is completed (below).

3.The Uterine incision:

3.1. Lower segment transverse incision:
- The uterus is inspected for fibroids, varicose veins and
adhesions. The two round ligaments are identified. Then the
uterus is palpated for fibroids and the presenting part.
- Moistened laparotomy packs may be placed in the para-
colic gutters.

- A Doyne retractor is inserted inferiorly. The loose serosa

overlying the lower segment of the uterus is held in the
middle with toothed tissue forceps and cut with scissor and
opened transversely just above (2 cm) the upper margin of
the bladder. The bladder is then reflected from the
underlying lower uterine segment, the bladder flap is held
beneath the symphysis pubis with the retractor.
- A transverse uterine incision is made by scalpel, avoid
injury of fetus. and extended the scissor (or fingers)
laterally and upward medial to the round ligament. In case
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 of transverse lie the incision is sometimes extended upward
(J shape).
The amniotic membrane is opened gently, continous
suction is useful to assist visualization and avoid fetal
injuries.
- Then the retractor is removed and if the fetal presentation is
cephalic it should be delivered by elevation through the
uterine incision manually.
- Fundal pressure should not be applied until the presenting
part is firmly in the incisional opening as otherwise the lie
of the fetus may turn to transverse.
- If the head is engaged in the maternal pelvis, disimpaction
by upward pressure per vagina is required.
- The nose and oropharynx of the baby are suctioned. and the
baby delivered by gentle traction.

- The infant is maintained at the level of the maternal

abdomen.
- If the presentation is breech the baby is delivered by
assisted vaginal delivery –as described in breech vaginal
delivery.

- Once the fetus is delivered oxytocin is administered 10 IU

bolus dose I.V and synotocinon infusion 40 IU in 500 ml
normal saline over 3 hours (80 milliunit/minute).

- The placenta is delivered by control cord traction-AFTER

BEING CERTAIN THAT UTERUS IS CONTRACTED
to avoid acute inversion of uterus. Manual removed of
placenta is associated with increased blood loss and
postpartum infection. The swab the uterine cavity and dilate
the cervix by ring forceps.

- Placement of Green Armytage at uterine angles and the

inferior uterine edge reduces the intraopretative blood loss.
- Exteriorization of uterus assist visualization and technically
facilitate repair especially if there have been lateral
extensions.
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- On occasion the lower uterine edge may be missed and the
posterior wall is mistaken for it- care should be taken to
avoid that. Also sometimes the lower segment is very thin
and hidden behind the visceral peritoneum which is stitched
instead
- The uterine incision should be closed in 2 layers using
Vicryl 2 or chromic cat gut (No 2).

- The initial stitch should be placed just beyond the angle

(corner). Each angle should be stitched separately before
completing the stitching of the incision.
- The second layer as inverted suture with continuous vertical
stitch to impregnate the myometrium over the first layer.

- Then haemostasis is assessed and any bleeding controlled

by figure of 8 stitch.

- The broad ligament is observed for haematoma, and if any

should be exposed and ligated.

- The visceral peritoneum is closed with chromic cat gut (0

or 1) or Vicry (0 or 1)

- The posterior wall of uterus is inspected and palpated for

evidence of tears which should be repaired.

- The pelvic organs are inspected and uterus retained to

peritoneal cavity.

- The gauzes and instruments and needles are counted at least

twice before closure.
Notice: Gauze inserted by doctor is the responsibility of the
doctor.

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 - The parietal peritoneum is closed by cat gut (0 or 1) or
Vicry (0 or 1).
- The recti should be approximated with interrupted sutures.

- The rectus sheath is closed with Nylon No 2 or Vicryl No 2

continous without interlocking.

- Closed drainage system of anterior abdominal wall may be

needed in obsese patients or in unsatisfactory haemostasis.

- Subcutaneous suture with No 1 cat gut is associated with

lower incidence of superficial wound disruption.

- The skin is closed with interrupted suture using Nylon 2 or

subcuticular suture using cat gut No 1.
- The wound is washed with Yamidin before the dressing.
3.3. Classical/Vertical incision
- Indications:
Pre-maturity (lower segment poorly developed) dense adhesions in
the lower segment, fibroids in the lower segment, anterior placenta
praevia with large vessels in lower segment, back down transverse
lie, interlocking twins.

- The abdomen is opened through a mid-line incision, 1/3 above umbilicus

and 2/3 below it.

- The position of the round ligaments is identified to ensure that the uterine
incision will be in the midline.

- The uterine incision is made in the midline vertically into the active
myometrium 12-15 cm and the lower limit should not extend to the utero-
vesical fold of peritoneum. The incision is made by scalpel up to the
membranes and then extended by scissors

- Pressure is applied on the edges to control bleeding

- Then the membranes are ruptured and the babyُs foot is grasped and baby
delivered.

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- Then the placenta and membranes are delivered.

- Then the edges are grasped with Allis or Green Armytage forceps.

- Then the incision is closed in 3 layers

o The first layer is closed close to the cavity-avoiding the decidua-
with continuous chromic cat gut (No2) or vicryl (No2).
o The second layer of the uterine muscle is closed –chromic 2 or
vicryl2.
o The superficial fibers and serosa are closed with continous chromic
2 or Vicryl 2 using atraumatic needle.

- Then the abdominal incision is closed.

- The woman should not labour with future pregnancies.

4. Post-Operative management :
- The patient should be observed on the operating table for at
least 30 minutes by the anaeSthetist and surgeon for: complete
recovery, bleeding, respiration, pulse and blood pressure.
- Tshen the patient is transferred to the resuscitation room (inside the
theatre) and observed every ½ hour for 2 hours
o uterine massage, bleeding, fundal status, pulse, blood pressure,
respiration, temperature
- Then the patient is transferred to the post-natal ward and observed (same
signs mentioned above) as follows
o Every hour for 4 hours
o Every 4 hours 24 hours
o Every 8-12 hours till discharge
- Fluid intake and output for 24 hours
- Syntocinon 40 IU in 500 ml saline infusion for 3 hours, 30 drops/minute
for hours
- Indwelling folleyُs catheter for 24 hours
- Third day Haemoglobin

Blood transfusion:
> 1000 ml loss: normal saline
≥ 1000 ml loss: blood transfusion.
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 Intravenous fluids:
3 liters in 24 hours (2 liters normal saline and 1 litre 5% Dextrose)

- Antibiotics:
Elective caesarean section:
- Two doses of third generation cephalosporin 1 g
intravenous; first dose 1/2 hour before operation and second
dose 12 hours later .

- OR: Cefazoline 1 g intravenous after clamping cord

- OR: Ampiclox 2g + Genatmycin 160 mg+ Metronidazole

500 mg infusion 1/2 an hour before start of operation.

Emergency and complicated caesarean Section:

Triple Regimen for 10 days. Gentamycin 5 mg/kg /24 hours
(80mg ampule 8 hourly)+Metronidazole infusion 500 mg 8
hourly+ Ampiclox 500 mg 6 hourly.

- Thromborophylaxis:
According to the guidelines on Thromboprophylaxis .start
24 hours after operation.

- Breast feeding:
Should start immediately after operation (spinal
anaethesia)and as soon as possible after general anaethesia.

- Disharge: After 7 days or longer if needed

Tubal ligation at caesarean section

- Obtain a written informed consent
- Ligation is done after completion of operation
- Grasp the least vascular middle portion of the fallopian tube with a

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- Babcock or Allis forceps. Then hold up a loop of tube 2.5 cm in length.
Crush the base of the loop and ligate with size 2 chromic catgut. Excise the
loop 1 cm in length. Repeat procedure on other side.

5. Complication of Caesarean Section:

- Anaesthesia related complications:
Spinal:
Hypotension, high spinal, spinal headache.

- General:
Inability to intubate or ventilate (obese), aspiration, inadequate ventilation,
respiratory failure, cardiac arrest.

- Haemorrhage: MOST IMPORTANT

Intraoperative is due to ATONY OF UTERUS (MOST IMPORTANT,
lacerations, placenta, coagulation problem.
- ATONY: MOST IMPORTANT Management in this order
1. Uterine massage
2. Pharmacological
3. Surgical.

1.1.Massage and bimanual compression

1.2. Pharmacological: In this order
- Syntocinon 20-40 units per litre intravenously
- Ergometrine 0.25 mg intramuscularly
- PGF 2α: 0.25 mg repeated every 15 minutes to a
maximum dose of 2 mg. Could be administered directory
in the myometrium.

1.3.Surgery in this order:

- Bilateral ligation of uterine arteries suture on lateral aspect
of uterus above the ureters.
- Bilateral ligation of uterine vessels medial to ovaries.
- B Lynch suture
- Hysterectomy

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 2. Lacerations:
- Common with malpresentaion, macrosomia, and thin
lower segment of obstructed labour.
- If lower segment is thin make the incision on lower
segment higher than normal.
- Other common lacerations are in the broad ligament and
vagina
- Expose the FULL EXTENT OF LACERATION and
repair starting with the first suture beyond the apex of the
laceration
- Broad ligament haematoma should be explored and
bleeding vessels ligated. be careful not to ligate ureter
- Hysterectomy is indicated if laceration extends inferiorly
and difficult to control bleeding

3.Placenta praevia /accreta

- At least 6 pints of blood should be prepared and operation
should be done by the most senior
- If severe bleeding in parous woman proceed for
hysterectomy
- If the uterus should be conserved, suture the placental bed
B lynch. Then hysterectomy is indicated if above measures
fail.

4. Coagulation Problems
Fresh blood.

Urinary tract injuries: Repair after completing operation

- The risk of bladder injury increases with Pfannenstiel
incision, repeat caesarean section and uterine lacerations.
- Bladder injury is reduced by the following measures: pre-
operative catheterization, peritoneal entery should be as far
cephalad as possible, sharp rather than blunt dissection of
bladder.

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 - If the bladder is injured (full thickness)it should be repaired
in two layers, continuous closure using 0 or 1 chromic cat
gut, the catheter should be left for 10-14 days.

Gastrointestinal injury: Rare: Repair immediately

- Risk increases with adhesions
- Full thickness defect of less than 1 cm is repaired in a double layer
transverse closure
- Defect more than 1 cm, call surgeon.

Wound infection:
- prophylactic measures: cleaning, shaving, use of iodine, sterile technique,
haemostasis, obliteration of dead spaces.
- Infected wound should be opened, culture the exudates and antibiotics.
- Debridement of necrotic tissues, use of antiseptic solution, saline lavage
must follow their application. Once granulation tissue appear, the wound is
approximated by secondary suture if large or allow to heal by secondary
intention if small.

Fascial dehiscence: Burst abdomen

- Presents with copious discharge and protrusion of bowel
- The bowel is covered with moist sterile gauze. The wound exposed,
cleaned, debrided and closed with retention suture or mass closure using
non- absorbable suture Nylon2.

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 GUIDELINES FOR THE MANAGEMENT OF NATURAL LABOUR

1. Introduction:
Of all experiences of the human condition, birth surely represents the most
important. Management of labour is the primary function of midwives and
obstetricians-in the Sudan more than 70% of normal deliveries are managed at
home by midwives. It is a physiological process and the role of the attendant is
very limited, yet WHO strongly recommend that natural labour should be attended
by a skilled birth attendant who can safely conduct the delivery and identify
complications. Some of those complications could be anticipated but many arise
without any prior warning. A women during labour needs sympathy,
encouragement support and continuous information about her condition and her
baby's condition.
These guidelines describe the physiology, mechanism and clinical Features of
labour to help the attendant diagnose normal and abnormal labour. The guidelines
describe the management in a systematic sequence.

Definition of labour:
1- Labour is the onset of regular painful uterine contractions, associated with
dilatation of the cervix and descent of the presenting part, a process by
which the products of conception (fetus, membranes, liquor and placenta)
are expelled from the mother via the birth canal.
- Definition of normal labour:
2- Labour which last 4 to 24 hours, at term ,spontaneous, without
complications and results in delivery of a baby, vertex presentation, alive
and without congenital abnormalities.

1- Onset of labour:
- The corpus uteri myometrium-smooth muscles relaxed during
pregnancy and contracts during labour.
- The cervix uteri-connective tissues ( mainly collagen) and few muscle
fibres closed during pregnancy and dilates during labour.
- Onset of labour is a result of complex endocrine changes leading to
maturation of fetus, corpus, cervix and placenta intimately linked.

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 - A large number of substances known to pqrticipate in the birth process.
 Key substances are:
1. Progesterone.
2. Calcium.
3. Oxytocin.
4. Prostaglandins PGE2 and
PGF2α.

2- Prelabour:

- Developmental phase of prepration for parturition (5-6 weeks).

- Activation of myometrium .
3- Individual myometrial fibre contracts when the two filaments actin and
myosin combine to form actinomysin (by the enzyme myosin light chain
kinase. The reaction requires calcium which is provoked by
oxytocin/PGF2α.
4- There is increased sensitivity to oxytocin due to increased receptors of
oxytocin on myometrium.
- Ripening of the cervix:
5- Softening of the cervix, degradation of the collagen and changes in the
ground substance proteoglycan complexes and increased water contents.
6- PGE2 causes vaso dilatation and permeability to neutrophils which enetr
the cervical stroma and release enzymes which degrade collagen.
7-
- Effacement of the cervix:
8- Is essential prerequisite to its dilatation and it depends on ripening of the
cervix.
9- Progressive shortening of the cervix from top (just below the
fibromuscular junction) downwards to the external os.
10- The cervix is now incorporated in the lower segment.
11-
12- Prostaglandins are essential for labour:
- PGF2α: myometrial contractions.
- PGE2: ripening of the cervix produced by amnion and decidua.

3- Clinical labour (true labour):

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 - Regular painful contractions which increase in frequency and intensity.
- Upper segment contracts and retracts.
- Lower segment stretches and dilates.

4- Component of natural labour:

(i) Powers
(ii) Passages
(iii) Passenger

(i) Powers:
- Primary forces: upper segment contracts and retracts. Lower
segment stretches and dilates.
- Normally 3-4 contractions in 10 minutes.
- Secondary forces: use of voluntray muscles (diaphragm and
anterior abdominal muscles).
- Pain during labour:
 First stage:
(i) Pressure on the nerve ending in
lower segment and cervix.
(ii) Anoxia of muscle fibres.
(iii) Dilatation of the cervix.
(iv) Stretching of visceral peritoneum.
Involves T11-L1.
 Second stage: Distension of vagina and
perineum.

(ii) Passages: ( soft-hard true- false)

Upper pelvis strait (inlet):

- Sacral promontory – iliopectineal line – posterior aspect of the
back of the pubis.
- True conjugate; Tip of sacral promontory to the upper margin
of the surface of the back of pubis.

Lower pelvic strait:

- Between the plane of least pelvic dimension (bounded by the
lower border of the symphisis pubis, ischial spine and the tip
of the sacrum) and the anatomical outlet of the pelvis (lower
14
 border of the symphisis pubis, pubic rami, ischial tuberosities,
sacro-tuberous ligament and tip of the coccyx).

Mid pelvic strait:

- Cavity of pelvis between the pelvic inlet and the plane of least
pelvic dimension.

The inlet is oval (longest diameter transverse); the mid cavity is circle; the lower
strait is oval (longest diameter antero-posterior).

Antero-posterior Diagonal Transverse

Inlet 11.5 cm 12 cm 13.5 cm
Cavity 12 cm 12 cm 12 cm
Outlet 13.5 cm 12 cm 11.5 cm

Types of pelvis:
1. Gynaecoid 50.6% most favourble
2. Android 22.7%
3. Anthropoid 22.7%
4. Platypeloid 4.4%

(iii)Passenger:

Regions of skull:
1. Vertex: Area between the bipariatal emenences and the anterior and
posterior fontanelles.
2. Occiput: Area between the posterior fontanelle and the lambdoid
suture.
3. Brow: Area between the supraorbital ridges and coronary suture.
4. Face: Area below the supraorbital ridges.

Diameters of the fetal skull:

Suboccipito bregmatic (9.5 cm): Vertex presentation from the suboccipital
region to the centre of anterior fontanelle.

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 1. Occipitofrontal (11.5 cm): occipitoposterior from root of the nose
to the posterior fontanelle.
2. Submento bregmatic (9.5 cm): Face presenation from below the
chin to the centre of anterior fontanelle.
3. Mentovertical (13 cm): Brow presenation from the chin to the
centre of vertex..
4. Biparietal diameter (9.5 cm).

Diagnosis of labour:
1. Painful regular contractions.
2. Progressive cervical dilatation with or without show or
spontaneous membrane rupture.

Course of labour:
First stage: from start to full dilatation of the cervix
12hours in primigravida
7 hours in multipara.
Second stage: from full dilatation of cervix to delivery of fetus.
2 hours in primimgravida.
1 hour in multipara.
Third stage: delivery of placenta 10- 20 minutes.

The passage of the fetus through the pelvis safely depends on:
- Efficient uterine contractions.
- Giving-in of pelvis.
- Moulding.
- Mother.
- Adaptation of fetal physiology to changes during labour.

Mechanism of labour:
In cephalic presentation the head is engaged with occiput:
Left occipito lateral (LOL)
Right occipito lateral (ROL)
Left occipito anterior (LOA)
Right occipito anterior (ROA)
Left occipito posterior (LOP)
Right occipoito posterior (ROP)
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Occipito anterior or occipito posterior (OA or OP)

1. Flexion.
2. Engagement.
3. Internal rotation.
4. Extension.
5. Restitution.
6. External rotation.
7. Lateral flexion of the body.

10 Definitions
Caput succedaneum:
Oedema over the presenting part: Dystocia.
Moulding:
- Fetal skull changes shape to adapt the pelvis. one parietal bone slides
over the other across the sagital suture and both parietal bones slide
over the occipital bone.
- Moderate moulding does not affect fetal brain.
- No moulding across frontal suture (face).

Presenting part:
- Lowest part of fetus palpable on vaginal examination.
- Normal = vertex.
- Any other presentation = malpresentaion.

Station of presenting part:

- Level in the pelvis reached by the presenting part.
- Ischial spine = station zero.
- Used to assess progress of labour( descent of the presenting part
through the pelvis) and calculate Bishop score.

Engagement of head:
- Biparietal diameter passed through the pelvic inlet (presenting part at
least at the level of the ischial spine).
- Biparietal diameter pass the ischial spine = head at lower pelvic strait.
- Role of fifths:
o The amount of head felt above the symphysis pubis.:
o 5, 4, 3 fifths = not engaged.

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 o 1,2,fifths engaged.

Crowning of the head:

- Biparietal diameter pass the anatomical outlet. Head does not receed
during relaxation.

Management of labour:
On arrival at labour ward use the admission sheet.
1. Date and time of arrival to the labour ward.

2. Full history: This will allow elucidation of most risk factors of difficult
labour and the information is used to guide the management e.g. preterm,
APH, scarred uterus, diabetes, twins ... etc.

3. Examination:
3.1. General.
3.2. Vital signs: Pulse ,BP, Temperature, RR.
3.3. Obstetrical – abdomen:
- Palpate for uterine contractions- assess.
- Fundal height, lie, position, presentation, engagement, fetal heart
sounds, amount of liquor and size of baby.
3.4. Vaginal examination (PV):
- Aseptic condition.
- Wash vulva and perineal area.
- First PV must be done the most experience person available ( usually
registrar).
- Findings:
 Vulva
 Vagina
 Cervix (effacement, dilatation, consistency
and position).
 Membranes: present or ruptured (amount of
liquor, colour, meconium, blood,
infection).
 Identify presenting part.
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  Determine station of presenting part.
 Moulding, caput.
 Pelvic assessment.

Diagnosis of labour:
- The accurate diagnosis of labour is essential because so much
depends on defining the starting point.
- However the diagnosis is sometimes difficult.
- Assess the uterine contractions carefully by palpation or CTG.
- PV: assess cervical dilatation.

1. If the diagnosis of active labour is confirmed, cervix ≤ 4cm, use a

partogram.
13- The time of admission iz the zero hour on the partogram.
2. If the diagnosis of active labour is not confirmed, cervix > 4 cm, keep the
patient in the labour room and repeat assessment after 3-4 hours and if still
not in active labour keep in labour room till the morning.
3. If the patient definitely not in labour, closed cervix and no contraction,
keep her in antenatal ward over the night. NEVER SEND A PATIENT
PRESENTING WITH LABOUR PAIN HOME IMMEDIATELY.
4. Patients who are definitely not in labour could be discharged in the
morning by consultant

First stage of labour (in the first stage room):

1. CTG: at least for 20 minutes for all patients at admission.
2. I.V line with dexrose 5% with normal saline at rate of 125 ml/hour.
3. Enema may be neded as directed by the doctor.
4. Bladder care: ask patient to void urine NO CATHETERISATION.
5. Investigations: Hb, urine (proteins, sugar, ketone bodies, blood), blood
group and rhesus factor.
6. Allow sips of water if patient not high risk.
7. Encourage mobilization.
8. Monitoring:
- Pulse : hourly.
- Blood pressure : hourly.
- Fetal heart : hourly. 1 min pinard.
- Uterine contractions : hourly palpation.
- Temperature : 4 hourly.

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 - Vaginal examination : 4 hourly or if there is fetal distress,
spontaneous rupture of membranes, vaginal bleeding or bearing
down.
- Vaginal examination : assess progress, meconium and membranes.
- CTG : at least 20 minutes for every patient.
Continuous for high risk patient.
 Abnormal recordings require increased
frequency of observation.
9. Analgesia: Pethidine 1.5 mg/kg body weight provided that delivery is
not imminent within the coming 3 hours. It can be given with 25 mg
Phenergan as anti-emetic.
10. Clinical findings are graphicaly represented in the partogram throughout
labour.

Partogram:
- The partogram is the method of graphically recording labour
observation against time.
- Time of diagnosis of active labour = zero hour.
- Devided into 3 sections:
 Upper part = fetal observations (fetal
heart +liquor +moulding).
 Central part = progress of labour
(cervical dilatation and descent of head
measured in fifth palpable abdominally,
uterine contractions).
 Lower part: maternal observations
(pulse, BP, Temp, urine, fluids, drugs,
syntocinon)
 Alert line: drawn in the active phase at a
rate of 1 cm/hour.
 Action line: parallel line to the alert line
4 hours to the right of it.

How to use the partogram:

1. Same partogram for primigravida and multipara.
2. Use when the patient is in the active phase ≥ 3 cm, latent phase missed out.
3. Completed by registrar/house officer.
4. Time of diagnosis of active labour = zero hour.
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 5. Record baseline findings.
6. Intervention at any time if there is: fetal distress – maternal distress –
haemorrhage.
7. Decision based on partogram and clinical observation .
7.1.1. If the patient’s graph remains on or to the left of the alert
line: No intervention, continue observation, (interfere if FD or
haemorrhage).
7.1.2. If the patient’s graph moves to the right of the alert line but
not reaching the action line:
- ARM + syntocinon in primigravida.
- ARM + observation in multipara.
7.1.3. If the patient’s graph reaches or crosses the action line:
- Careful assessment of mother and fetus (progress,
FD, obstructed labour) and if indicated C/s.
- If no abnormality detected continue observation and
syntocinon (primigravida).
- Labour should not continue for more than 7 hours
beyond the action line.
8. Latent phase > 4cm (8 hours):
- Usually not in labour – no intervention.
- Genuine prolonged latent phase is rare.
- If any problems arise e.g. FD, haemorrhage do C/S.
- If doctor thinks that the patient is in genuine labour (prolonged
latent phase) do ARM + syntocinon.

Second stage of labour:

1. In the second stage room – Delivery table.
2. Diagnosis of second stage:
- Bearing down.
- Vaginal examination = cervix fully dilated.
3. The length of second stage is 2 hours in primigravida and 1 hour in
mutligravida provided that the labour is progressing, no fetal distress, no
maternal distress or haemorrhage. The attending doctor may choose to
deliver mother earlier if he/she judges so.
4. Fetal heart auscultation following each contraction.
5. Maternal pulse and blood pressure ½ hourly between contractions.
6. Lithotomy position.
7. Mother pushes during contractions.
21
 8. Episiotomy (if indicated) after local infiltration or pudendal block at
crowning of the head.
9. Support perineum to prevent extension of the head before the biparietal
diameter passes through the vulva.
10. After delivery of the head look in the nuchal area for cord around the neck.
11. Deliver anterior shoulder and then posterior shoulder and sweep the baby
towards mother, delivery of the body and legs.
12. Keep newborn below or at the level of the mother.
13. Clamp and cut the cord after one minute.
14. Deliver placenta, give Ergometrine 0.25 mg im and repair episiotomy (if
done).
15. If there is no progress despite active pushing, vaginal examination is
performed to detrmine descent, position, caput, moulding. If all excluded
(there is no evidence of obstructed labour, caput, brow, face etc) and no
good uterine contractions then give syntocinon (in primigravida) and wait
for one hour in multigravida.

Third stage of labour:

1. Delivery of placenta in 10-20 minutes
2. Ergometrine 0.5mg intramuscular or syntocinon 5 IU intra-muscular upon
delivery of anterior shoulder or immediately after delivery of baby.
3. Catheterize bladder
4. Then after 3-5 minutes deliver the placenta by controlled cord traction after
confirming that the uterus is well contracted
5. Give syntocinnon 30 units in 500ml saline- 30 drops/min for 3 hours in high
risk patients or insert misoprostol 800 microgram per rectum
6. Examine placenta, cord and membranes and document.
Third stage of labour
1. Delivery of placenta in 10-20 minutes
2. Ergometrine 0.5 mg intramuscular or syntocinon 5 IU intramuscular upon
delivery of the anterior shoulder or immediately after delivery of baby.
3. Catheterize placenta
4. Look for signs of placental separation (small gush of blood, lengthening of
cord, uterus … globular and rises up to umbilicus)
5. Then deliver the placenta by controlled cord traction after confirming that the
uterus is well contracted.
6. Give syntocinon 40 iv in 500ml normal saline at a rate of 15 drop per minute
22
for 4 hours
- 80 millunits per minute. In high risk case OR: misoprostol 800 microgram per
rectum
7. Examine placenta, cord and membranes and document.
1. Delivery of placenta in 10-20 minutes.
2. Ergometrine 0.25 mg intramuscular (I.V) or syntocinon 10 units I.V (I.M)
upon delivery of the anterior shoulder.
3. Look for signs of placental seperation (small gush of blood, lengthening of
the cord, uterus firm globular and mobile and rises up to umbilicus).
4. Deliver placenta by controlled cord traction after confirming that the
uterus is well contracted.
5. Syntocinon 30 units in 500 ml normal saline 30 drops per min for 3 hours
in high risk cases or misoprostol 800 miscrogram per rectum.
6. Examine placenta, cord and membranes and document.

4th stage of labour (2 hours):

- Continue infusion of syntocinon.
- Every patient should be observed for two hours in the labour room,
before transferring her to the ward (pulse, blood pressure,
contracted uterus and vaginal bleeding) ½hour.

Before transferring to the ward:

Observe and record:
- Vital signs.
- Uterine contraction.
- Vaginal bleeding.

In the ward:
- Hand over the patient + her last observation record (pulse, BP,
Temp, respiration, uterine contraction and vaginal bleeding) to the
ward nurse who should sign on the records.

23
 GUIDELINES FOR THE MANAGEMENT OF:
PROLONGED LABOUR AND OBSTRUCTED LABOUR
OCCIPITO-POSTERIOR, FACE BROW

1. Introduction:
Dystocia (difficult labour, prolonged labour and obstructed labour) is a commonly
encounterd obstetric problem and the care of women experiencing it is one of the
greatest challenges in obstetric practice. It is the commonest indication of
caesarean section and contributes significantly to maternal mortality and
morbidity. Obstetricians will need to be expert at all aspects of care for women
with dystocia. Prolonged labour is linked to many factors among them are occipito
posterior, face and brow.
These guidelines describe the causes, methods of diagnosis and management of
dystocia, occipito posterior, face and brow. They also describe methods of
diagnosis of fetal Distress during labour.

Prolonged labour in primigravida

 Prolonged labour in primigravida

 An abnormality which may be detected during labour and for which a

cause must be found by examining the patient clinically.

 Failure of cervical dilatation 1 cm per hour in the active phase ≥ 4cm.

 Accurate diagnosis of active phase is essential.

Causes:
1. Powers inefficient uterine action (most important):

— Normal contractions = 3- per 10 minutes.

— Abnormal contractions = contractions which do not result in

normal progress of labour (dilatation of cervix and descent of
presenting part)

— Hypotonic, incoordinated

24
 2. Passages:

2.1. Pelvic contractionand abnormalities.

2.2. Cevical dystocia (amputation, cautery, cone biopsy).
2.3. Vaginal septum (thick near cervix).
2.4.Fibroid lower segment.

3. Passenger –fetus:
3.1. Malpresentation and malposition.
3.2. Macrosomia – big baby.
3.3. Hydrocephalus.
3.4. Shoulder dystocia.
3.5. Congenital malformations.

NOTE: ALL ABOVE CAUSES MAY BE DIAGNOSED BUT THE MAIN

CAUSES FREQUENTLY ENCOUNTERED ARE:
1. Inefficient uterine action.
Treated by oxytocin infusion.

2. Occipito posterior position.

When contractions are ineffecient give oxytocin→ adequate.
Contractions → correct position.

3. Contracted pelvis = caesarean section.

Management:
1. Use the partogram in the active phase ≥ 4 cm.

2. When active labour is diagnosed ≥ 4 cm = zero hour.

3. Careful monitoring of mother + fetus + hydration + analgesia.

4. FETAL DISTRESS AT ANY TIME IN FIRST STAGE = CAESAREAN

SECTION.

5. Any other abnormality e.g. hypertension, haemorrhage → treat

appropriate.

6. Patient curve on or at the left of alert line = no intervention.

25
 7. Patient curve on the right of the alert line:

 Adequate hydration and analgesia.

 ARM: clear adequate liquor is reassuring.

: Scanty liqour anticipate difficulties.

: Meconium liquor: fetal distress.
 Syntocinon: 1 mu/minute, double every 30 minutes, maximum
32mu/minute.

8. Patient curve on or to the right of action line:

— Thorough reassessment of mother, fetus, progress of labour.

— Continue oxytocin + hydration + analgesia.

— Allow labour for 4-6 hours to the right of the action line maximum
7 hours → caesarean section.

Occipito- posterior position:

1. Normal position: vertex presents with occipito-anterior position (LOL,
ROL, LOA, ROA, OA) in 90% of cases.

2. In 10-20% : labour starts with the occiput posterior, usually right occipito-
posterior.

— 80% rotates to occipito-anterior.

— Few continue as persistent OP.

— Few progress to deep transverse arrest.

3. Head engages as OP”

— Small baby.

— Anthropoid pelvis.

— Deliver face to pubis safely.

26
  Diagnosis:

 Abdominal: flat abdomen, fetal parts anterior, difficult to

feel the back, fetal heart heared at flanks.

 Per vaginal examination :

 Early in labour:

Head is high and anterior fontanelle occupies the centre.

The posterior fontanelle is high and sagital suture
anteroposterior.
 Late in labour:

Membranes ruptured.
Moulding, caput.
Posterior fontanelle felt posteriorly (one parietal bone
overlap the other and both overlap the occipital bone).
Feel the ear.

Features of labour:
 Large diameter presents (occipito-frontal 11.5 cm)

 Prolonged, obstructed labour.

 Early rupture of membranes.

 Genital tract laceration.

Management:
1. Use partogram in the active phase ≥ 4 cm.

2. Monitoring, hydration and analgesia.

3. Curve to the left or on alert line → no intervention.

Curve to the right of alert line: ARM + syntocinon.

Curve on or to the right of action line: careful assessment
wait for 4-6 hours → caesarean section.

27
 4. Mode of delivery:
4.1. Fetal distress or maternal distress or haemorrhage or cord
prolapse in the first stage = caesarean section.
4.2. Failure of progress (7 hours to the right of the action line) after
ARM and syntocinon = caesarean section.
4.3. Fetal distress or maternal distress in the second stage and head
not engaged = caesarean section
NEVER ATTEMPT A FORCEPS.
4.4. First stage, head not engaged and no fetal distress or maternal
distress = syntocinon and wait for engagement.
4.5. Fetal distress or maternal distress in the second stage and the
head engaged = forceps or vacuum.
Deliver face to pubis with forceps.
4.6. If good progress, no fetal or maternal distress, allow vaginal
delivery face to pubis.
4.7. Deep transverse arrest = caesarean section.
4.8. Rotation of the head:
 Do not use kielland forceps for correction of OP or
deep transverse arrest.

 Manual rotation of head if not in direct OP before

application of forceps.

Prolonged labour in multiparous women:

Causes:
1. Inefficient contractions.

2. Fetus:

 Malpresentation.

 Malposition.

 Big baby.

 Hydrocephalus.

 Malformed baby.
28
Management:
1. Use partogram in the active phase ≥ 4 cm.

2. Monitoring, hydration and analgesia.

3. Curve to the left or on alert line → no intervention.

4. Curve on or to the right of alert line:

 Careful assessment.

 ARM – NO SYNTOCINON.(should be prescribed only

after discussion with the consultant )

5. Curve on or to right of action line:

1. Very very very careful assessment (fetal size, fetal distress,
vaginal examination – engagement position caput liquor,
maternal distress)

2. Wait for 4-6 hours after action line → caesarean section.

Obstructed labour:
 Failure of progress in the presence of frequent, regular
strong contractions. Mechanical obstruction.

Causes:
1. Contracted pelvis, abnormalities (primigravida).

2. Fetal:

— Malpresentation, malposition.

— Big baby.

— Hydrocephalus.

— Shoulder dystocia.

— Malformed baby.

29
Diagnosis:
1. Use partogram in active phase ≥ 4 cm.

2. Clinical features are usually diagnosed with prolonged labour (diagnosed

by partogram) but sometimes appear earlier (transverse lie, brow
presentation, hydrocephalus, big baby).

Features: clinical examination (vital signs, abdomen, PV)

1. Exhausted, dehydrated, anxious, sweating, pain.

2. Tachycardia, rise in temperature , vomiting.

3. Abdomen:

— Detect cause of obstruction (big baby, malpresentation).

— Strong frequent contractions (palpation – CTG).

— Thick upper segment – retracted.

— Thin distended lower segment.

— Bandle ring.

— Hypertonic uterus – tender.

— Presenting part not engaged.

— Fetal heart: fetal distress or IUFD.

4. Vaginal examination:
— Oedema of the vulva.

— Vaginal discharge (offensive, meconium, blood).

— Cevix:

 Could be fully dilated.

 Thick and unequally dilated.

 Thick anterior lip.

30
  Not well applied, hanging.

- Presenting part:
 Identify (OP, brow, face, etc).

 Station of the presenting part usually high but could be low

(primigravida).

 Moulding.

 Caput.

Management:
1. Hydration.

2. Swap for culture and sensitivity.

3. Antibiotics. third generation cephalosporin 1 g IV

4. Caesarean section – most cases whether baby is alive or dead.

5. Craniotomy:

— Hydrocephalus dead.

— Dead baby, primigravida, head at introitus.

Fetal distress in labour:

1. Causes:

 Dystocia, prolonged and obstructed labour.

 Preterm labour.

 Induction of labour, syntocinon.

 Malpresentation and malposition.

 Chorio-amnionitis.

 Prolapse of cord.

 Antepartum haemorrhage.
31
  Maternal diseases, hypertension, diabetes.

 Intra uterine growth retardation.

2. Diagnosis:
 Diagnosed by fetal heart monitoring, meconium and fetal
scalp PH.

 Always determine risk when interpretating e.g. prolonged

labour.

2.1. Fetal heart – intermittent auscultation one minute.

 Normal: 110 - 140 – 160 per minute.

 bradycardia > 110 per minute.

 Tachycardia < 160 per minute.

2.2. Meconium:
 Thick meconium : significant.

 Thin / light meconium : some degree of stress.

2.2.3 Fetal scalp PH : less than 7.2 (Not available).

Cardiotocography (CTG):
Continous electronic record of fetal heart and uterine contractions.
Indications:
1. Prolonged labour.

2. Trial of labour.

3. Preterm labour.

4. Induced labour.

5. Augmented labour.

6. Breech presentation.

7. PROM and early rupture of membranes.

32
 8. Scarres uterus.

9. Multiple pregnancy.

10. Antepartum haemorrhage.

11. Diabetes, hypertension, renal disease.

12. Intra uterine growth restriction.

13. Abnormal fetal heart on auscultation (Pinard).

14. Cardiac disease.

Interpretation:
DR C BRAVADO
— Determine Risk (DR) : e.g. prolonged labour.

— Contractions (C) : frequency, relation of fetal

heart.

— Baseline Rate (BRA) : between contraction.

— Variability (V) : change of fetal heart 10-15

beat/ minute.

— Acceleration (A) : increase in fetal heart

— rate.
—

— Deceleration (D) : decrease in fetal heart rate.

— Overall assessment (O) : reassuring or not.

Normal CTG:
1. Baseline fetal heart : 110 – 160.

2. Variability < 5 beat per minute .

3. Acceleration : Reactive.

4. No deceleration.

33
Abnormal CTG: Not reassuring.
1. Baseline: Tachycardia or bradycardia.

2. Absent variability.

3. No acceleration.

4. Decelerations.

— Late decelerations after contraction

management of fetal distress:

— Stop syntocinon.

— Lateral position.

— Facial oxygen.

— Caesarean section.

Face presentation:
— Head is hyperextended.

— Secondary during labour.

— Associated with:

 Big baby.

 Contracted pelvis.

 Pendulous abdomen of grandmultipara.

 Anencephalic fetus.

Diagnosis:
— Relies principally on the vaginal examination.

— Feel: frontal bones, supra-orbital ridges, eyes, nose, mouth and

chin.

34
 — Differentiate between mouth and anus.

 Mouth: alveolar margin, suckling reflex, mouth and

maxillary bones form a triangle.

 Anus: straight line with ischial tuberosities.

Labour:
— Face bones are not compressible.

— Presenting diameter is submento-pregmatic (9.5 cm).

— Early rupture of membranes.

— Prolonged and obstructed labour.

— Mento-lateral rotates to mento-anterior and head is delivered by

flexion.

— Mento-posterior could rotate to mento anterior and deliver

vaginally.

— Vaginal delivery of persistent mento posterior is impossible.

— Management:

Evaluate the mother carefully after diagnosis and decide:

— Caesarean section:

o Contracted pelvis.

o Scarred uterus.

o Big baby.

o Persistent mento-posterior.

— Vaginal:

o No indication for caesarean section.

o Mento-lateral or mento-anterior.

o Monitor and expect dystocia and fetal distress.

35
 o Syntocinon contraindicated.

o Forceps could be used in mento-anterior.

o Vacuum extractor contraindicatesd.

Brow presentation:
— Incidence 1:1000.

— Aetiology similar to face.

— Causes obstructed labour.

— Diagnosis:

Per vaginal examination:

 Feel: frontal suture, anterior fontanelle, orbital ridges, eyes
and root of the nose (mouth and chin not felt).

 Presenting diameter: mento-vertical = 13 cm.

— Delivery:

 Syntocinon contraindicated.

 Caesarean section.

36
 GUIDELINES FOR INDUCTION OF LABOUR

1. Introduction:
- Induction of labour is one of the most frequent medical procedures in
pregnancy. It is a major intervention with the potential to set in motion a
cascade of interventions particularly caesarean section.
- It decreases perinatal mortality (reduce risk of intrauterine fetal death
from: diabetes mellitus, pre-eclampsia prolonged pregnancy, amnionitis,
Rh isoimmunization)
- It improves certain medical condition in the mother which are either
caused or aggravated by pregnancy: pre-eclampsia, placental abruption,
intrauterine fetal death.
- It is associated with certain risks to the mother (uterine hyperstimulation,
caesarean section, infection, ruptured uterus and PPH) and risks to fetus
(prematurity and serioun neonatal morbidy fetal distress). Even though it is
less morbid than caesarean section.
- Definition: An intervention designed to artificially initiate uterine
contrations leading to effacement and dilation of cervix and birth of the
baby

2. General objective:
To perform planned initiation of labour when the risk to the fetus or to the
mother of pregnancy continuation over weigh the risk of termination.
3. Details of guidelines
3.1. Make sure that there is a strong indication (maternal and/or fetal):
- Post dates (12 days or more beyond the EDC.)
- Maternal disease (hypertensive disorder, diabetes mellitus, deteriorating
illness)
- Oligohydramios.
- Prolonged pre-labour ruptured membranes (37 weeks or more)
- Unexplained antepartum haemorrhage (mild abruption)
- Rhesus isoimmunization

- NEVER INDUCE WITHOUT INDICATION

37
3.2. Make sure that is no contra-indication
- Grand multipara
- Scarred uterus
- Intrauterine fetal restriction
- Major degree contracted pelvis

3.3. Check for maturity of baby

- Menstrual gestation age LMP
- Early Ultra sound scan before 20 weeks
- Clinical and/or U/S estimated size of baby

3.4. Calculate the Bishop Score

(A standardized method of semi quantitative clinical scoring of the cervix).

PARAMETER /SCORE ZERO 1 2 3

Cervical dilation/cm closed 2-1 4-3 5<
Cervical length/cm 2 < 2 1 >1
Cervical consistency Firm Mediu Soft -
m
Cervical position Posteri Central Anterior
or
Station -3 -2 -1or zero Below zero

3.5. Assess fetal wellbeing biophysical profile and CTG

3.6. Methods
- Sweeping of membranes:
Sweeping of membranes at term reduces the incidence of post-dates and reduces
the need for the use of formal methods of induction.
It should be done for all women at term and always prior to formal induction. It is
not associated with an increase maternal or neonatal infection.

FOR VIABLE BABY WHEN THE PISHOP SCORE IS 7 OR MORE

- Induce in the labour room at 9.00 aim on the duty day of the unit.
- Start prophylactic antibiotics third generation cephalosporin I.V
- Take blood for grouping and crossmatching, prepare 2 units of blood.
- DO ARM: cervix should be effaced and 3-4 cm dilated

38
 o With sterilized gloves sweep the membranes of the cervix
o At the same time exclude cord presentation
o Rupture the forewaters by Kocherُs forceps or amniook
- Give syntocinon by titration or automatic pump.
- Follow progress of labour
CLOSELY MONITOR FETUS AND MOTHER
- Combination of ARM+Syntocinon are the best when the cervix is
favourable
- Avoid ARM in HIV patients, it increases incidence of fetal infections
- If regular contractions are not established after using the maximum dose of
syntocinon for 5 hours, proceed to caesarean section (failed induction)

FOR VIABLE BABY WHEN THE BISHOP SCORE 15 < 7

- Induce in the labour room at 9.00 aim on Unitُs day
- Insert Prostaglandin E2 (Prostin) tablet 3 mg high in the posterior fornix of
the vagina and start prophylactic antibiotics cefazoline 1 g iv.
- If no response after SIX hours insert the second dose THE MAXIMUM
DOSE IS 6 mg.
- If no response after SIX hourse from the second dose and the membranes
are intact, diagnose failure of induction, reassess fetal and maternal
conditions. Send the patient to the antenatal ward and re-plan her.
- If there is response do ARM and start Syntocinon-6 after prostaglandin

Note:
- Prostaglandin E2 tablets are preferred to gel
- Either Prostaglandin or Oxytocin may be used when induction of labour is
undertaken in nulliparous or multiparous women who have ruptured
membranes, regardless of cervical status, as they equally effective.
- If vaginal delivery is not achieved in 24 hours (end point of induction of
labour)proceed for caesarean section

Misoprostol:
NB: Misoprostol is not licenced for induction of labour with a viable fetus
- Is an orally active, stable prostaglandin El analogue.
- Can be used: Orally, vaginal, buccal sublingual, rectal
- Use Misoprostol in primigravidae with viable fetus and a Bishop score <
7.(unfavourable cervix)
o Tablet= 200 ug
39
 o Insert 25 ug in posterior vaginal fornix the tablet should be
softened with water before insertion
o If there is no response repeat the dose every 4-6 hours to a
maxiumum of 3 doses per day
NEVER insert misoprostol at 9.00 pm.
o If no response after third dose, repeat the following day
o If no response the second day, diagnose failure and procced for
caesarean section
o If there is a reponse – Bishop score <7 and cervix 3-4 cm dilated,
do ARM and give syntocinon 6 hours after the last tablet.
o Oral Misoprostol:
 More rapid, less sustained
 Dose=25ug 2 hourly
 If smaller doses are needed.Dissolve 200 ug (tablet)in 200
ml water and shake well and give the dose planned. Discard
solution after 12 hours.

Complications of Misoprostol:
- Uterine hyperstimulation, meconium stained liquor, precipitate delivery,
ruptured uterus.
- No significant difference in perinatal outcome versus other methods
- Postpartum haemorrhage.

FOR INTRA UTERINE FOETAL DEATH

- Expectant management for 3 weeks
- Do all investigations for coagulopathy (CBC,PT,APTT, Platets, clotting
time fibrinogen, D. diamer)
- Crossmatch 2-4 units of blood
- Start induction before 9.00 aim
- Use Misoprostol in a dose according to gestational age: 200-800 ug initallt
vaginally. Repeat every 4-6 hourse every 4-6 hourse if no response.
- The second line is Prostag landing E2 vaginal
- The third line is antiprogestens (Mifepristone). Give 600 mg orally as a
single dose for 2 days under medical supervision
- Give Syntocinon if there is response
- Aroid repeated vaginal examination (infection)
- NEVER rupture the membranes
- Anticipate PPH.
40
 GUIDELINES FOR SYNTOCINON THERAPY

- Syntocinon is a synthetic form of oxytocin, a posterior pituitary hormone

- Indications
o Induction of labour
o Augmentation of labour
o Second trimester abortion
o Third stage of labour
o Post partum haemorrhage

- Absolute contra-indications (when used for induction of labour or

augmentation).
o Previous caesarean section and other scars of uterus
o Grandmultipara
o Fetal distress
o Evidence of obstruction (caput, moulding)

- Important Notice:
o In augmentation of labour a vaginal examination should be
performed before the start of infusion to exclude signs of
obstruction (caput, moulding etc)
o Syntocinon can be used to induce labour in a primigravida (or
multiparous) women who have ruptured membranes, regardless of
the condition of the cervix.
o Is given always after rupture of membranes
o Is given in Normal saline to avoid maternal and fetal
hyponatraemia
o Start with the minimum possible dose then increase by titrating the
dose against uterine contractions, to reach the effective dose(3-4
contractions per 10 minutes)
o Adequate contractions (3-4/10 minutes) may be established at 12
milliunits per minute. The licensed maximum dose is 20 milliunits
41
 per minute . If higher doses are used the maximum dose should not
exceed 32 milliunits per minute.

Dose:
- FOR TITRATION OF THE INFUSION
o The dose of syntocinon is expressed in milliunit per minute. So
changing the rate of the same infusion will change the dose.
o 1 unit of syntocinon in 1000 ml: I milliunit per ml
o 1 unit of syntocinon in 500 ml:2 milliunit per ml
o 1ml =15 drops
o 1 unit of syntocinon in 500 ml 0.9%normal saline:
 15 drops per minute =2 milliunit per minute
 30 drops per minute=4 milliunit per minute
 60 drops per minute=8 milliunit per minute.

Titration of infusion:
Dose of syntocinon in 1 ml/min 2 ml/min 4ml/min
500 ml saline 15 drops/min 30 drops/min 60 drops/min
1 unit syntocinon 2 milliunit/min 4 milliunit/min 8 milliunit/min
2 unit syntocinon 4 milliunit/min 8 milliunit/min 16 milliunit/min
5unit syntocinon 10 milliunit/min 20 milliunit/min 40 milliunit/min
10 unit syntocinon 20 milliunit/min 40 milliunit/min 80 milliunit/min

- The regimen for Primigravida:

o Use 5 unit syntocinon in 500ml saline (10 milliunit per ml) and
start with 8 drops per minute (5 milliunit perminute). Then increase
to 15 drops per minute (ie 10 milliunit per minute). The infusion
rate is doubled every 30 minutes until contractions are 3-4 in 10
minutes.
o Increase to 30 drops per min=20 milliunit per min
o Increase to 45 drops per min=30 milliunit per min (this is the
maxiumum dose allowed)
o Avoid high rates of drops (60/min) as that may cause circulatory
over load INSTEAD USE HIGH DOSE AND LOW RATES OF
INFUSION (15 DROPS and 30 DROPS).

42
 - The regimen for multiparous (para2-4):
o Start with 2 units syntocinon in 500 ml normal saline (4 milliunit
per ml) with 8 drops (ie 2 millianit/min) and increase to 15 drops
per minute (ie 4 milliunit per minute). The infusion rate is doubled
every 30 minutes until contractions are 3-4 in 10 minutes
o Before giving syntocinon for induction or augmentation the women
must be carefully evaluated by a CONSULTANT in WRITING.
Eeven though, beware of hyperstimulation
o Multiparous on syntocinon must be VERY CLOSELY
MONITORED.

NB: In induction of labour, once labour is established the infusion rate may be
progressively reduced- as the myometrial sensitivity increases-to a rate of about 7
milliunit per minute.

FOR AUTOMATIC INFUSION PUMP

- Put 10 units of syntocinon in 500 ml 0.9% normal saline (20 milliunit per
ml)
- Start by 2 milliunit per minute (6mls/hour-6 mls=6× 20 milliunit
= 120 milliunit. i.e 120 milliunit per hour =120/60 minutes=2 milliunit per
minute)

- Double the dose every 30 minutes till you reach 3-4 contactions in 10
minutes.

Doe of syntocinon using the automatic pump:10 units of syntocinon in 500

ml normal saline ie 20 milliunit per ml.
6 ml /hour 2 milliunit/min
12 ml / hour 4 milliunit/min
24 ml / hour 8 milliunit/min
36 ml / hour 12 milliunit/min
48 ml / hour 16 milliunit/min
96 ml / hour 32 milliunit/min

NB:WOMEN ON SYNTOCINON MUST BE CLOSELY MONITORED

Prevention of postpartum haemorrhage:
Syntocinon 30-40 units in 500 ml 0.9% normal saline for 3 hourse (40
drops/min) following the third stage.
43
GUIDELINES FOR THE MANAGEMENT OF PREMATURE RUPTURE
OF MEMBRANES (PROM)

1. Introduction:
Occurs in 2% of all pregnancies and accounts for one third of pre-term
delivery . The latency period to spontaneous labour is inversely
proportional to the gestational age. The most frequent consequence of
preterm premature rupture of membranes is pre-term delivery:50% within
a week, 75% within 2 weeks and 85% within a month. At term 90% of
patients are in labour within 24 hours. The other important complication is
chorioamnionitis. Both complications increase the risk of perinatal
mortality.

2. Definitions:
- Premature rupture of membrances (PROM) is
spontaneous rupture of membranes one hour or more
before the onset of labour

- Preterm premature of membranes (PPROM) is PROM

before 37 weeks.

3. Causes:
The exact aetiology is unknown. It is associated with certain risk factors:
history of PROM, incompetent cervix, cervical or vaginal infection (group
B streptococcus, bacterial vaginosis, Mycoplasma, gonorrhoea,
Chlamydia, Ureplasma)

4. Complications
4.1 Preterm labour
4.2 Chorioamnionitis
- Maternal pyrexia and tachycardia, tender uterus, fetal
tachycardia, offensive vaginal discharge (late)
- rise in WBC and C-reactive protein.

44
5. Diagnosis
- History of fluid leakage, gushing of fluid (do not confuse
with profuse vaginal discharge or urine)

- Exact dating of pregnancy; LMP and U/S

- Abdominal: fetal size, presentation and contractions fetal

heart, uterine tenderness.
- Speculum examination
o STERILE SPECULUM
o Liquor coming through the cervix is diagnostic (no
need for further tests) if no liquor through cervix
apply gentle fundal pressure.
o Look for liquor in the posterior vaginal fornix
o Observe liquor; colour, amount, blood, meconium,
pus
o pH: Normal pH of vagina=4.5-6
pH of liquor =7.1-7.3.
o Inspect cervix for dilatation
o Take high vaginal swap for culture+ sensitivity
NEVER DIGITAL EXAMINATION

- Ultra sound
o Oligohydramnios
o Gestational age
o Fetal abnormalities

6. Management of PPROM (Before 37 weeks)

- Conservative management in the absence of uterine
contractions, chorioamnionitis or fetal distress.

- Admit and observe:

o maternal pulse, temperature and fetal heart rate 6
hourly
o daily CTG
o HVS and CBC twice per week

45
 o U/S assessment for biophysical profile and Doppler
weekly
o Growth scans every two weeks.

Time of Delivery:
- Immediate termination of pregnancy (induction or
caesarean section if there is an added factor) if there are
clinical signs of chorioamnionitis.
Meconium is siagnostic of sepsis in preterm pregnancies
- Give intravenous intrapartum antibiotics (third generation
cephalosporin+ metronidazole)
- Give same antibiotics if labour starts spontaneously and
manage as pre-term labour
- If drainage of liquor stops, no contractions no infection
and condition of fetus is reassuring, induce at 37 weeks
OR: wait for spontaneous vaginal delivery
- If the gestational age is less than 34 weeks the patient
could be discharged home if the drainage stops and no
evidence of infection or contractions or fetal distress.

7. Management of PROM (37 weeks) or more

- Admitt to the labour room and observe

heart rate 4 hourly
- Abdomen: size of baby ,lie, presentation, contractions
- CBC, HVS, Urine culture
- Erythromycin+Metronidazole+ corticosteroids (as above)
- U/S for biophysical profile and CTG
- If spontaneous labour has not ensured after 24 hours
induce labour by syntocinon if the cervix is favourable, if
the cervix is not favourable use PGE2 or Misoprostol
vaginally and then syntocinon. Give I.V prophylactic
antibiotics (3rd generation cephalosporin+Metronidazole).
Syntocinon decreases incidence of infection without
increasing rate of C/S.

46
 - If at any time during the 24 hours follow up the patient
develops one of the followings, induce labour
immediately
- Maternal pyrexia
- Offensive vaginal discharge
- Meconium stained liquor
- Fetal tachycardia

- If PROM after 37 weeks with an added factor (breech,

scarred uterus, multiple pregnancy) terminate by
immediate CS.

47
 GUIDELINES FOR THE MANAGEMENT OF PRE-TERM LABOUR

1. Introduction:
Pre-term labour is defined as labour which occurs between 28 weeks and 36
weeks+6 days gestation. It is associated with higher perinatal morbidity and
mortality. The actual diagnosis of pre-term labour is sometimes difficult. It is
diagnosed when there are regular painful uterine contractions-or uncomfort- with
or without cervical dilation.
The prognosis of pre-term infant is significantly affected by:
- Gestational age and birth weight
- The use of steroids to mature the lungs of very immature fetuses
- The condition of the infant during labour and at birth and
immediate neonatal management
- The availability of intensive care unit.

2.Risk factors for pre-term labour :

In many cases no risk factor is identified
- Prior pre-term labour
- Preterm premature rupture of membranes (PPROM)
- Advanced maternal age and adolescence
- Low socioeconomic status
- Maternal infection (Urinary, Bacterial vaginosis, intra-uterine
infection,TORCH, viral hepatitis
- Multiple pregnancy, hydramnios
- Incompetent Os; fibroids
- Abruptio placentae
- Trauma: accident or surgery (appendicitis)
- Malaria

3. Management:
3.1. Diagnose pre-term labour
3.2. Assess gestational age (LMP, fundal hight and U/S)
3.3.Attempt to find a cause especially intra-uterine infection and bleeding
3.4. Decide: Expedite Observe Suppress
3.5. Care of the newborn
48
History:
- Drainage of liquor
- Frequency and duration of contractions
- Past history of pre-term labour
- Symptoms of generalized infection or UTI e.g. fever
- Past history of middle trimester abortion

Examination:
- Pulse, BP, Temperature
- Palpation for any abdominal pathology e. g pyelonephritis, acute
appendicitis
- Uterine contractions-duration and frequency-by palpation and CTG
- Fetus: Hight of fundus, size of baby, presentation, lie level of
presenting part, fetal heart, amniotic fluid
- Vaginal Examination: STERILE+++
 Speculum to inspect for liquor
 High vaginal swap for culture
 Full cervical assessment
- Urgent investigations:
BF, HVS, MSU, WBC, CTG, U/S(gestation age and viability and
congenital malformation).

Management:
1. Observation:
Do not inhibit uterine contraction, give steriods, manage labour, be ready for
delivery and care of newborn.
- More than or equal 36 weeks
- Good size baby
- Multiple pregnancy
- Medical problems: Diabetes, hypertension
- Maternal disease contradicting drugs of inhibition
- Ruptured membranes
- Active labour advancing-4 cm or more

- Regular monitoring hourly for mother and fetus for signs of infection and
fetal distress

49
 - Antibiotics are not given routinely unless there is infection or spontaneous
rupture of membranes.
- Caesarean section if fetal distress in the first stage of labour.

2. Suppression of labour and steroid administration .

- Steroid therapy: for fetal lung maturity

- Given in ALL cases of pre-term labour
- Dexamethazone 12 mgs intramuscularly 12 hours apart (6 mg 4
doses 12 hours apart) or: Betamethazone 12 mgs IM 2 doses 24
hours apart.
- Improves lung maturity, intestine and myocardium and reduces risk
of necrotizing colitis and interventricular haemorrhage.
- Should not be repeated.

Tocolytic Therapy:
- Less than 36 weeks, single, cervix less than 4 cm, membranes
intact and no associated indication of induction
- Monitor maternal and fetal condition hourly (pulse, BP, temp,
contractions, fetal heart, bleeding, fluid balance)

Indomethacin
Dose: 100 mg rectally 12 hourly for 48 hours. If further tocolysis is
required give 50 mg orally TDS for 5 days.

Contra-indications:
- Gestation greater than 32 weeks –to avoid premature closure of
ductus arteriosus
- Maternal Asprin allergy
- Maternal renal disease
- Fetal renal disease
- Severe oligohydramnios

Expediting labour
- Significant vaginal bleeding with a clinical diagnosis of abruption
placentae
- Intra-uterine infection as indicated by maternal pyrexia and tender
uterus
50
 - IUFD or apparent malformation
- Prolonged rupture membranes < 24 hours

- Give syntocinon+antibiotics.

Labour and Delivery

- Once it is clear that labour is going to occur stop tocolytic drugs
- Inform Neonatal unit
- Continue fetal monitoring
- Vaginal delivery, Cephalic or breech.
 No routine episiotomy, done if there is delay
 Forceps rarely needed
 Vacuum contra-indicated.

51
GUIDELINES FOR THE MANAGEMENT OF BREECH PRESENTATION

1. Introduction:
- Breach presentation is defined as the fetal breech presenting in the
birth canal and the head in the uterine fundus.
- Types:
 Incomplete, frank, extended:60-70%. Thighs flexed at hips,
legs extended at knees. External cephalic version (ECV) is
difficult. Easy engagement.
 Complete: Flexion at hip and knee, irregular presentation
affects engagement.
 Footling: One or boths hips and knees extended with one or
both feet presenting.

- Vaginal delivery of breech is associated with increased risks to the

fetus (stillbirth and injuries) and mother (dystocia and lacerations)
and hence caesarean section is the method of choice of breech
delivery in some countries. In the Sudan breech is delivered
vaginally if it is not associated with any complication.

- These guidelines describe the ante-partum management of breech

presentation and the details of techniques of vaginal delivery.

2. Risk factors for Breech: Predisposing factors

- Pre-maturity, high parity, uterine anomalies, fetal anomalies, pelvic
tumours, polyhydramnios olighydramnios, absolute cephalopelvic
disproportion (contracted pelvis), placenta praevia, previous breech,
multiple pregnancy.

3. Antepartum management:
3.1. Attempt to find a cause e.g placenta previa, prematurity-by a
formal U/S scan. Often no cause is found
3.2. Attempt maternal position exercise to turn breech
3.3. Attempt External cephalic version (ECV)
3.4. Determine most favourable mode of delivery-elective
caesarean section or assisted vaginal delivery.
52
3.3. External Cephalic version ECV.

3.3.1. Factors associated with success multipara, frank breech,

normal or increased amniotic fluid, relaxed uterus, tocolysis,
acoustic stimulation.

3.3.2.Contra-indications to ECV:
Multiple pregnancy, utero-placental insufficiency, no-
reassuring fetal heart CTG, uterine anomalies, placenta praevia,
unexplained bleeding (APH), hypertension, scarred uterus, heart
disease, vaginal delivery not possible, ruptured memberanes

3.3.3. Complications of ECV

Fetal bradycardia, decelerations, Abruption, fetal
haemorrhage, maternal haemorrhage, knotted or entangled
cord, fetal death, amniotic fluid embolus- death, premature
labour,
3.3.4.ECV procedure:
- Review for indication
- Done in hospital where caesarean section could be done
immediately
- Done at 37 weeks gestation
> 37= pre-term
< 37 =difficult
- Success: 60% in multipara and 40% in primigravida.
- Plapate the abdomen to confirm the presentation and
position of the fetal head, back and hips. Listen to the fetal
heart and do not proceed if > 110 or < 160. Do U/S: to
confirm presentation, back and liquor.
Do CTG 20 minutes before procedure and do not proceed
if not reassuring
- Fasting, nothing by mouth
- Ask patient to empty the bladder
- Set I.V line
- 0.25 mg turbutaline subcutaneous 15 minutes before start.

53
 - Put patient in Trendelenbreg position (on her back, elevate foot
of bed)

- To mobilize the breech, gently lift the lowest part of the fetus
from the pelvic inlet by grasping above the pubic bone.
- Bring the head and buttocks of the fetus closure to each other
(flex fetus) and then rotate the fetus slowly in direction of nose.
When the fetus is just past the transverse, it may rotate without
undue effort. Then guide head to the pelvis

- Listen to fetal heart and/or CTG during ECV

- If ECV is successful do CTG for 30 minutes and if reassuring

and no contractions send patient to antenatal ward. Council
patient to report if there is bleeding or pain.

- If no success after 15 minutes stop the procedure

- If there is severe pain or bradycardia, stop the procedure
- If bradycardia persist, deliver mother by immediate caesarean
section.

3.4. If ECV fails Decide:

- Elective C/S
- Or Assisted vaginal delivery.

3.4.1. Indications of elective C/S:

Hypertension, diabetes mellitus, APH, big baby(≥3.8 kg),
contacted pelvis (>4.5" true conjugate), IUGR, previous still birth,
relative infertility, scarred uterus, footling, primigravida,
hydrocephalus, hyper extended head, nuchal arm, lack of
experienced birth attendant.

3.4.2. Vaginal Breech Delivery

- Adequate pelvis, multipara, weight > 3.8 kg, no associated
complications, significantly malformed baby

54
First Stage:
- Assess mother and fetus-history+ examination
- Use partogram
- Look for cord prolapse
- Monitor mother and fetus
- PREPARE PATIENT FOR EMERGENCY CAESAREAN
SECTION WHICH MAY BE INDICATED AT ANY TIME
(FETAL DISTRESS, MATERNAL DISTRESS or FAILURE
OF PROGRESS-NO SYNTOCINON)

Second stage:
- The largest part of fetus is delivered last.
- Spontaneous: rare
- Breech extraction: Only second twin+ complication

Assisted vaginal Breech delivery:

- Empty the bladder
- Cervix must be fully dilated
- Look for cord prolapse
- Once the buttocks have entered the vagina tell the patient to
bear down with contractions.
- When the perineum is distended (breech climbs the perineum)
do episiotomy under pudendal block.
- Deliver the buttocks and legs. If complete breech deliver the
feet and legs and buttocks. If frank breech push behind the knee
to bend the leg and then grasp the ankle and deliver the foot and
leg and repeat for other leg.
- Hold the baby by the HIP (not by the flanks or abdomen as this
may cause kidney or liver damage)BACK ANTERIOR
- WAIT. DO NOT PULL (as this stretch the arms above
head)UNTIL THE UMBILICUS IS DELIVERD)
- Then a loop of cord is gently pulled down to prevent tension on
cord and allow monitoring of fetal heart.
- Then deliver the arms when the tip of fetal scapula appear. The
arms are normally flexed in front of the chest.

55
  The anterior arm is swept down across the fetal chest
and out of introitus and then the posterior arm is
delivered in the same way.

- Delivery of arms stretched above the head or folded around the

neck use Loveset’s maneuver.
The posterior shoulder which is below the scaral
promontory is brought anterior and below symphysis
pubis by rotating the fetus clockwise and applying
downward traction at the same time. After delivery of
the shoulder which has come anterior the fetus is turned
in the anticlockwise to bring the second shoulder
anterior and below the symphysis bubis and be
delivered

- If the babyُs body can not be turned to deliver the arm that is
anterior first, deliver the shoulder that is posterior.
o Hold and lift the baby by the ankles
o Move the babies chest towards the womenُs inner leg.
The shoulder that is posterior should deliver.
o Deliver the arm and hand
o Lay the baby back down by the ankles. The shoulder
that is anterior should now deliver. Then deliver the arm
and the hand.

- Delivery of head:
o Allow baby hang by gravity (supported); that enhances
flexion and engagement. Nape of neck under symphysis
pubis indicates engagement.
o Then deliver head

- Mauriceau Smellie Veit

o Lay baby face down with length of body saddled over
your right arm

56
 o Place the first and third fingers of your right hand on the
babyُs maxilla bones to flex the head.
o Use the other hand to grasp the babyُs shoulders.
o Gently flex the babyُs head- while an assistant applies
suprapubic pressure-and apply shoulder traction and
deliver the head.
o Raise the baby’s still astride the arm until the mouth and
nose are free.
- Burns Marshal maneuver:
Stand on the right side of patient and swing the trunk
towards the maternal abdomen unti‫ م‬the mouth and nose
are visible.
- Forceps
Piper- Neville Barnes Forceps-long forceps: lift body
upwards, apply left blade and then right blade and
deliver the head. Use forceps to flex and control
delivery of head. Used when MSV fails or as an elective
procedure.

o Breech extraction
 Second twin, breech, with complication
 Insert hand in uterus and grasp the babyُs foot.
 Hold the foot and pull it out throught the vagina
 Gently pull the foot until the back and shoulder
blades are seen
 Proceed with the delivery of arms.
 Give a single dose of prophylactic antibiotics.

Footling breech:

- Usually delivered by C/S

- Vaginal delivery: advanced second stage.
- Delivery of additional baby in multiple pregnancy
- Grasp the babyُs ankles with one hand.
- If only one foot presents, insert the hand into vagina and gently
pull the other foot down.
- Gently pull the baby downwards by the ankles.
57
 - Deliver the baby until the back and shoulder blades are seen.
- Proceed with delivery of arms and head.

Post delivery care

- Suction the baby’s mouth
- Clamp and cut the cord
- Give syntocinon 10 I.V within active management of third
stage of labour
- Examine the patient carefully, repair episiotomy and other tears
if present.

58
 GUIDELINES FOR INSTRUMENTAL VAGINAL DELIVERY

Introduction:
The aim of these guideline is to provide information on the use of the forceps and
vacuum extractor for operative vaginal deliveries. Obstetricians should be
confident and competent in the use of both instruments. The anatomy of the birth
canal and the fetal head must be understood as a prerequisite to becoming skilled
in the safe use of the forceps or vacuum extractor. It is recommended that
obstetricians achieve experience in spontaneous vaginal delivery prior to
commencing training in operative vaginal delivery. The goal of operative vaginal
delivery is to mimic spontaneous vaginal birth, thereby expediting delivery with a
minimum of maternal or neonatal morbidity.

Background:
Operative vaginal delivery rates have remained stable at between 10% and
15%.There has been an increasing awareness of the potential for morbidity for
both the mother and the baby. The risk of traumatic delivery in relation to forceps,
particularly rotational procedures, has been long established, although with careful
practice overall rates of morbidity are low. Also warning about the potential
dangers of delivery with the vacuum extractor were issued. This followed several
reports of infant fatality secondary to intracranial haemorrhage. In addition, there
has been a growing awareness of the short- and long-term morbidity of pelvic
floor injury following operative vaginal delivery. It is not surprising, therefore,
that there has been an increase in litigation relating to operative vaginal delivery.
Caesarean section in the second stage of labour, however, also carries significant
morbidity and implications for future births. If we are to offer women the option
of a safe operative vaginal delivery, we need to improve our approach to clinical
care. The goal should be to minimise the risk of morbidity and, where morbidity
occurs, to minimise the likelihood of litigation, without limiting maternal choice.

59
General objectives:
To identify the indications, pre-requesites and to aquire practical skills of
instrumental veginal delivery.

Indications for operative vaginal delivery

(no indication is absolute and each case should be considered individually).

Indications:
Fetal: Fetal distress in the 2nd stage of labour.
Maternal: Medical indications to avoid Valsalva (e.g. cardiac disease Class III or
IV, eclampsia, a hypertensive crises, cerebral vascular disease, particularly
uncorrected cerebral vascular malformations, myasthenia gravis, spinal cord
injury)
Inadequate progress Nulliparous women: lack of continuing progress for three
hours (total of active and passive second stage labour) with regional anaesthesia,
or two hours without regional anaesthesia
Multiparous women: lack of continuing progress for two hours (total of active and
passive second stage labour) with regional anaesthesia, or one hour without
regional anaesthesia
Maternal fatigue/exhaustion

Prerequisites for operative vaginal delivery

Full abdominal and vaginal examination:

1. Head is ≤ 1/5 palpable per abdomen
2. Vertex presentation
3. Cervix is fully dilated
4. Membranes ruptured
5. Exact position of the head can be determined so proper placement of the
instrument can be achieved
6. Pelvis is deemed adequate

60
Mother:
1. Informed consent must be obtained and clear explanation given
2. Appropriate analgesia is in place, A pudendal block may be appropriate,
particularly in the context of urgent delivery
3. Maternal bladder has been emptied recently, indwelling catheter should be
removed or balloon deflated
4. Aseptic techniques

Staff :
1. Operator must have the knowledge, experience and skills necessary to use
the instruments
2. Adequate facilities and back-up personnel are available
3. Back-up plan in place in case of failure to deliver
4. Anticipation of complications that may arise (e.g. shoulder dystocia,
postpartum haemorrhage)
5. Personnel present who are trained in neonatal resuscitation

VACUUM EXTRACTOR:
 Review for conditions:
- Vertex presentation.
- Term fetus.
- Cervix fully dilated.
- Fetal head at least at 0 station or no more than 2/5 palbable above the
symphisis pubis.
- Membranes are ruptured.
 Check all connections and test the vaccum on a gloved hand.
 Provide emotional support and encouragement.
 Use a pudendal block

 PUDENDAL BLOCK:
- Prepare 40 mL 0.5% lignocaine solution without adrenaline.
- It is best to limit the pudendal block to 30 mL of solution so that a
maximum of 10 mL of additional solution may be injected into the
perineum during repair of tears, if needed.
- Use a 15 cm, 22-gauge needle to inject the lignocaine.

61
- Infiltrate the perineal skin on both sides of the vagina using 10 Ml of
lignocaine solution.
- Aspirate (pull back on the plunger) to be sure that no vessel has been
penetrated. If blood is returned in the syringe with aspiration, remove
the needle. Recheck the position carefully and try again. Never inject if
blood is aspirated. The woman can suffer convulsions and death if IV
injection of lignocaine occurs.
- Wearing high-level disinfected gloves, place two fingers in the vagina and
guide the needle through the perineal tissue to the tip of the woman’s left
ischial spine.
- Inject 10 mL of lignocaine solution in the angle between the ischial spine
and the ischial tuberosity.
- Pass the needle through the sacrospinous ligament and inject another 10
mL of lignocaine solution.
- Repeat the procedure on the opposite side.
- If an episiotomy is to be performed, infiltrate the episiotomy site in the
usual manner at this time.
- At the conclusion of the set of injections, wait 2 minutes and then pinch
the area with forceps. If the woman can feel the pinch, wait 2 more
minutes and then retest.
- Anaesthetize early to provide sufficient time for effect

 Wear a high-level disinfected or sterile gloves, assess the position of the

fetal head by feeling sagittal suture line and the fontanelles.
 Identify the posterior fontanelle.
 Apply the largest cup that will fit (Better siliastic cup, Metalic cup is
suitable in occipitoposterior), with the centre of over the flexion poin, 1cm
anterior to the posterior fontanelle. This placement will promote flexion
and autorotation with traction.
 An episiotomy may be needed for proper placement at this time, if an
episiotomy is no necessary for placement, delay the episiotomy until the
head is stretching the perineum or the perineum interferes with the axis of
traction. This will avoid unnecessary blood loss.
 Check the application. Ensure there is no maternal soft tissues (cervix or
vagina) within the rim.
 With the pump, create a vacuum of 0.2 kg/cm2 negative pressure and
check application.
62
  Increase the vacuum to 0.8 kg/cm2 and check the application.
 After maximum negative pressure, start traction in the line of the pelvis
axis and perpendicular to the cup. If the fetal head is tilted to one side or
not well flexed, traction should be directed in a line that will try to correct
the tilt or deflexion of the head (i.e. to one side or the other, not
necessarily in the midline).
 With each contraction, apply traction in a line perpendicular to the plane of
the cup rim. Place fingers on the scalp next to the cup during traction to
assess potential slippage and descent of the vertex.
 Between contractions check:
- Fetal heart rate.
- Application of the cup.

 Paediatrics staff should attend the delivery.

 Active management of thirs stage of labour.
 AFTER PROCEDURE DOCUMENT ALL THE OPERATION IN
PATENT RECORD

TIPS
 Never use the cup to actively rotate the fetal head. Rotation of the fetal
head will occur with traction.
 The first pulls help to find the proper direction for pulling.
 Don’t continue to pull between contractions and expulsive efforts.\
 With progress, and in the abscence of fetal distress, continue the “guiding
pulls” for a maximum of 30 minutes.

FAILURE:
 Vacuum extractor failed if:
- Fetal head not advance with each pull.
- Fetus is undelivered after 3pulls with no descent, or after 30
minutes.
- Cup slips off the head twice at the proper direction of pull
with a maximum negative pressure.
 Every application should be considered a trial of vacuum
extraction. Do not persist if there is no descent with every pull.
 If vacuum extraction fails, perform a caesarean section.
63
Complications:
Complications usually results from not observing the condition of application or
from continuing efforts beyond the time limits stated above.

Fetal complications:
 Localize scalp edema (caput) under the vacuum cup is harmless and
disappears in a few hours.
 Cephalohaematoma requires observation and usually will clear in three to
four weeks.
 Scalp abrasions (common and harmless) and laceration may occur. Clean
and examine lacerations to determine if sutures are necessary. Necrosis is
extremly rare.
 Intracranial bleeding is extemely rare and require immediate intensive
neonatal care.

Maternal complications:
 Tears of the genital tract may occur. Examine the women carefully
and repair any tear to the cervix or vagina or repair episiotomy.

64
FORCEPS DELIVERY:
 Review for conditions:
- Vertex presentation or face presentation with the chin anterior
(mentoanterior) or after-coming head in breech delivery.
- Cervix fully dilated.
- Fetal head at +2 or +3 station or 0/5 palbable above the
symphisis pubis.
- At minmum , the sagittal suture should be in the midline and
straight, making sure an occiput anterior or occiput posterior
position.
- Membranes should be ruptured.
 Provide emotional support and encouragement. Use pudendal block.
 Assemble the forceps before application. Ensure that the parts fits
together and lock well.
 Adequate anaesthesia (pudendal block as described above).
 Lubricate the blades of the forceps.
 Wearing high-level sterile gloves, insert two fingers of the right hand
into the vagina on the side of the fetal head. Slide the left blade gently
between the head and fingers to rest on the side of the head.
 Repeat the same manoeuvre on the other side, using the left hand and
the right blade of the forceps.
 Depress the handles and lock the forceps.
 Difficulty in locking usually indicates that the application is incorrect.
In this case, remove the blades and recheck the position of the head.
Reapply only if rotation is confirmed.
 After locking, apply steady traction inferiorly and posteriorly with
each contarction.
 Episiotomy is indicated.
 Between contractions check:
- Fetal heart rate.
- Application of forceps.
 When head crowns, make and adequate episiotomy.
 Lift the head slowly out of the vagina between contractions.
 Paediatrics staff should attend the delivery.

The head should descend with each pull. Only two or three pulls should be
necessary.
65
Failure:
 Forceps failed if:
- Fetal head does not advance with each pull.
- Fetus is undelivered after three pulls with no descent or after 30
minutes.
 Every application should be considered a trial of forceps. Do not persist if
the head does not descend with every pull.
 Active management of tird stage of labour.
 If forceps delivery fails, perform a caesarean section.
 AFTER PROCEDURE DOCUMENT ALL THE OPERATION IN
PATENT RECORD

Complications:
1. Fetal complications:
 Injury to facial nerves requires observation. This injury usually
resolves spontaneously.
 Lacerations of the face and scalp may occur. Clean and examine
lacerations to determine if sutures are necessary.
 Fractures of the face and skull require observation.
2. Maternal complications:
 Tears of the genital tract may occur. Examine the woman carefully and
repair any tears to the cervix or vagina or repair episiotomy.
 Uterine rupture may occur and require immediate treatment.

66
 GUIDELINES FOR THE MANAGEMENT OF CORD PROLAPSE

1. Introduction :
The cord is below or along side the presenting part in the presence of
ruptured membranes. The cord becomes compressed between the
presenting part of the fetus and the pelvic wall resulting in asphyxia or
death. It is a rare condition associated with certain risk factors which
should be used to anticipate it. It is a true obstetric emergency which
needs- sometimes-urgent interventions.
These guideline describe the methods of diagnosis, risk factors and
treatment.

2. Risk factors:
High head, malpresentation and malposition, polyhydraminos, multiple
pregnancy, prematurity.

3. Diagnosis:
- The umbilical cord is visible outside or felt in the vagina during
vaginal examination
- When the membranes rupture-spontaneous or artificial-auscultate
the fetal heart and perform vaginal examination. The only hint may
be severe variable deceleration or bradycardia (CTG) following
rupture of membranes.

4. Management:
Depends on whether fetus is alive or dead, the stage of labour, gestational
age and other factors e. g transverse lie

4.1. Fetus alive: call peadiatrician for resuscitation

- First stage of labour:
- If the cord is pulsating, the fetus is alive.
- Do immediate vaginal examination to diagnose the stage of
labour
- Relief pressure on the cord by:
o replace the cord in the vagina using warm gauze, Do not
attempt to replace the cord in the uterus.
67
 o Dislodge the presenting part to keep pressure off the cord
and continue doing so until caesarean section.
o Position patient in knee-chest position or exaggerated
Sims position
o Elevate presenting part by filling bladder with normal
saline.
o Give mother Oxygen by face mask
o Transfer to the theater and perform immediate caesarean
section
- Second stage:
o If the woman is in the second stage deliver immediately
by forceps or vacuum extractor
o If breech presentation, deliver by caesarean section
o If delivery is not considered to be possible e.g. high head,
big baby, scarred uterus, the delivery should be by
caesarean section.
4.2. Fetus dead
- If the cord is not pulsating at the time of the initial examination,
it should be ascertained using an U/S or CTG and if alive
proceed to caesarean section.
- If the fetus is confirmed dead, deliver in the manner that is
safest to the mother-vaginal if no contra-indication or caesarean
section if: scarred uterus (2+), big baby, transverse lie.

5. Cord presentation:
The cord is below the presenting part but the membranes are intact. If at 37
weeks or more deliver by emergency caesarean section to prevent cord
prolapse.

68
 GUIDELINES FOR THE MANAGEMENT OF SCARRED UTERUS

Introduction:
Is a uterus which has served from a previous uterine surgical scar. The pregnancy
is labeled as high risk pregnancy.
The surgery might be:
1. One transverse lower segment caesarean section.
2. Classical (upper segment).
3. Perforation scar.
4. Two or more lower segment caesarean sections.
5. Repair of uterine rupture.
6. Myomectomy.
7. Hysterotomy.

Management oflabour with scarred uterus:

 A woman in labour and has scarred uterus for a previous uterine surgery.

 General management:

o 2 large canulae (14-16 g) and start an I.V infusion of I.V fluids.

o Full preparation of caesarean section with preparation of blood.
o If possible identify the reason for the uterine scar. Caesarean
section or other reason.

o 2 previous caesarean section or more are not for trial of sacr

and delivery should be by repeat caesarean section.
o Medical condition like hypertension or diabetes with previous
sacar is for delivery by caesarean section.
o Placenta praevia with previous scar is for delivery by caesarean
section

69
  The scar could be weakened the uterus leading to uterine rupture during
labour:
o Vertical scar for a previous caesarean section ma rupture before
labour or during the latent phase.
o Transverse lower segment scar typically rupture during active
phase or expulsive phase .
o 2-4 previous scars may got dehescence during late pregnancy
which could be silent and discovered during caesarean section.
o The rupture may extend only for a short distance in the
myometrium with a little pain or bleeding. The fetus and placenta
may remain inside the uterus and may survive for a period of time.

Specific management:
Trial of scar: (should be in a place where facilities for emergency
caesarean are available).
 Ensure that the conditions are vafourable for trial of labour:
 The previous scar is a low transverse scar.
 The fetus is a singleton with cephalic presentation
 The feus is average size and weight estimated.
 There is no added medical factor (hyperetension, diabetes).
 U/S showes no placenta praevia.
 No history of post-operative infection which meight affect the
healing of the uterine scar.

 If these conditions are not met the delivery is by repeat caesarean

section.
 Monitor progress of labour using a partogram.
 If labour exeeds the alert line of the partogram, diagnose the cause of the
slow progress and take appropriate action.
 If there is slow progress due to inefficient uterine contractions,
rupture the membraneswith amniohook or Kocher forceps and
assess the a moun and colour of the amniotic fluid.

 NO AUGMENTATION WITH SYNTOCINON

70
 If there are signs of cephalopelvic disproportion or obstructed labour
deliver immediately by caesarean section.
 If there are signs of impending uterine rupture: (rapid maternal pulse,
perssistent abdominal pain and suprapubic tenderness, fetal distress,
vaginal bleeding) , deliver immediately by caesarean section.
 If uterine rupture is suspected , deliver immediatelyy by caesarean section
and repair of the uterus or perform hysterectomy.

 Misoprostol is not allowed in previous scar.

 Syntocinon is not allowed in previous scar.

71
 GUIDELINES FOR THE MANAGEMENT OF SHOULDER DYSTOCIA

1.Introduction:
Shoulder dystocia is defined as impaction of the anterior shoulder against the
maternal symphysis pubis after the fetal head has been delivered. It occurs when
the bisacromial dimeter (breadth of the shoulders) exceeds the diameter of the
pelvic inlet. Incidence: it is a rare complication which varies based on fetal weight
0.3%-1% : 2500-4000 grams
5%-7%: 400-4500grams
50% occur in the normal birth weight and are unanticipated.
A focused calm systematic approach to this emergency is needed considering
TIME
These guidelines describe the risk factors which help in anticipation, the diagnosis
and the techniques of management.

2.Risk factors
 Macrosomia, diabetes mellitus, obesity, post-dates pregnancy,
abnormal pelvic anatomy, previous shoulder dystocia, short stature
 Prolonged first stage, prolonged second stage, forceps, vacuum
extractor
 Note: Only half of the cases have risk factors- half are unpredictable.
Therefore all doctors and midwives should be familiar with the
management.

3. Complications
- Fetal death, brachial plexus palsy, fracture clavicle, fracture
humerus, fetal hypoxia with or without neurologic damage
(once the fetal head is delivered it must be assumed that the
umbilical cord is compressed between the fetal body and
maternal pelvis).
- Postpartum haemorrhage, third or fourth perineal tears, recto-
vaginal fistula, ruptured uterus, symphyseal separation.
4. Diagnosis

72
 - The fetal head is delivered but remains tightly applied to the
vulva. The head emerges and then retracts up against the
perineum (turtle sign)
- The chin retract and depresses the perineum
- Traction on the head fails to deliver the shoulder which is
caught behind the symphysis pubis.

5. Management-Reduction maneuvers
- The order of maneuvers should be in the same order of the mnemonic
HLPERR (ALSO)
- H - Call for help
- E - Episiotomy
- L -Legs (The Mac Roberts Maneuver)
- P - Supra pubic pressure
- E - Enter-Internal maneuver
- R - Remove the Posterior arm
- R - Roll the patient

- 30-60 seconds for a maneuver, if fails then move to the second

maneuver. Total time allowed is 3-5 minutes
- WATCH TIME THROUGHOUT

- H: Shout for HELP.

Urgently mobilize all available personel
- E: Episiotomy:
Make adequate episiotomy to reduce soft tissues
obstruction and to allow space for manipulations
- L: Legs (Mac Roberts Maneuver)
 With the women on her back, flex the maternal hips, thus
positioning the maternal thighs up onto the maternal
abdomen (this increases the inlet diameter, straightens the
lumbosacral lordosis, flattens the sacral promontory).
 The midwife or family member can assist.
 Attempt delivery in this position for 30-60 seconds
 This maneuver alone can deliver 40%. Combined with
suprapubic pressure and episiotomy can deliver 50%.
 Avoid excessive traction on the fetal head as this may cause
brachial plexus injury.
73
 - P: Supra-Pubic pressure
 An assistant should simultaneously apply supra-pubic
pressure downwards while the doctor is applying firm
continuous traction downwards on the fetal head to
dislodge the shoulder from behind the symphysis pubis.
 The assistant hand should be placed over the fetus anterior
shoulder-adduct or collapse shoulder.
 Do not apply fundal pressure as this will further impact the
shoulder and can result in uterine rupture.
- E: Enter-Internal maneuver
If the shoulder is still not delivered
 Insert a hand into vagina along the babyُs back.
 Apply pressure to the anterior shoulder in the direction
of the babyُs sternum to rotate the shoulder and
decrease the diameter of the shoulders.
 If needed apply pressure to the posterior shoulder in the
direction of the sternum.

- R-Remove the posterior arm

 The posterior arm is removed from the birth canal, this
shortens the bisacromial diameter.
- Insert hand into the vagina in the hallow of the sacrum.
Locate the forearm and keeping the arm flexed at the
elbow, deliver the forearm in a sweeping fashion over
the anterior chest wall. Deliver posterior hand, arm and
finally the shoulder.
This will allow the anterior shoulder disimapct and
deliver.

If all the above measures fail to deliver the anterior shoulder:

- Fracture the clavicle by direct upward pressure on the midpoint of the
fetal clavicle, that will decrease the width of the shoulder
- Apply traction with a hook in the axilla to extract the arm that is
posterior.
- If the fetus dies perform cleidotomy

Postpartum: check for: PPH, lacerations, uterine rupture and anal sphincter.
Syntocinon infusion for 4 hours.
74
GUIDELINES FOR THE MANAGEMENT OF MULTIPLE PREGNANCY

Introduction:
Multiple pregnancy is now rather common, the incidence ranges between 4/1000-
54/1000. It contributes very much to the perinatal mortality and morbidity. Almost
all maternal problems and complications occur more in multiple pregnancy than
singleton pregnancies and they are usually more serious. Delivery of multiple
pregnancy commonly necessitates manipulations no longer practiced in singleton
pregnancy.
It may be suspected in the following groups of women with
- Family history
- Fundal hight more than dates
- Multiple fetal parts and the palpation of 3 poles or more
- Assisted reproduction.

Diagnosis is confirmed by U/S scan; chorionicity could be determined particularly

if U/S is done in first trimester (100 accuracy).

Complications of multiple pregnancy

- Anaemia: specially folic acid deficiency
- Pre- term labour
- Pre-eclampsia
- Abnormal lie and abnormal presentation
- Intra-uterine growth restriction
- Primary post partum haemorrhage.

Management during pregnancy:

- Frequent ante-natal visits, iron and folic acid supplementation and
serial growth scan.
- Advise rest in bed at home and admit for hospital delivery as early as
possible.

Indications of elective caesarean section

- First twin breech or transverse
- Scarred uterus
- Ante-partum haemorhage
75
 - Diabetes, hypertension etc
- Triplets or more

Notice: No place for induction of labour and do not allow pregnancy to prolong-
postdates-especially monochorionic twins

Management during labour:

- Pre-term labour is managed as singleton;
Do not forget steroid therapy.
- Vaginal delivery is allowed when there is no indication for caesarean
section (above)
- The first stage is usually managed as in singleton pregnancy
o Partogram and record base line vital signs (pulse, BP, temp,
respiration)
o Determine lie and presentation of first twin by abdominal
examination, vaginal examination and U/S if needed.
o Perform CTG for both fetuses.
o Determine cervical dilation by PV
o Prepare blood.
o Inform Neonatal unit
o Monitor progress of labour according to the normal criteria for
cephalic singleton.

DELIVERY:

Twin 1:
- An oxytocin drip should be ready (10 iu syntocinon in 500 m/s normal
saline)
- Perform episiotomy under local anesthesia at the crowning of head.
- Deliver the baby in the routine way for singleton
- Stabilize the lie of twin 2 as twin 1 is delivering.
- The delivery of the first twin is usually followed by a short silent pause
in which the uterine contractions cease and the abdominal muscles
relax and one should do abdominal examination.
Twin 2:
- Immediately after delivery of twin 1 the lie of twin 2 should be
determined by abdominal examination and vaginal examination and
U/S.
76
 - If longitudinal (cephalic or breech) the membranes are ruptured with
the next contraction provided that the head or breech is fixed in the
pelvis.
- If there is uterine atony-expected-then oxytocin infusion should be
commensed and the membranes are ruptured only when there are
contractions and the head/breech is fixed. Then deliver the baby:
routine if cephalic and by assisted breech delivery if breech.
- If the lie is transverse external podalic or cephalic version must be
performed as quickly as possible (intact membranes) and baby is
maintained manually in the longitudinal lie until the head/breech is
fixed in the pelvis and the membranes ruptured artificially. Rupturing
the membranes will maintain the lie and accelerate labour. Then the
baby is delivered cephalic or breech.
- After delivery of twin 2 abdominal examination should be performed
to exclude the presence of a third fetus.
- The third stage should be managed actively (intramuscular ergometrine
and CCT). An oxytocic infusion should be continued (40 iu syntocinon
in 500 ml normal saline over 3 hours or misoprostol rectally 800
micrograms)
- Keep woman for 4 hours in labour room and monitor (Pulse, BP,
vaginal, uterine contraction)hourly.
- Keep woman in postnatal ward for 24 hours and monitor 6 hourly
(Pulse, BP, Vaginal bleeding and uterine contractions)
- If the lie is transverse and external version fails or if the membranes
rupture spontaneously before version, then the baby is delivered by
caesarean section.

Possible complications after delivery of the first twin:

1. Inefficient uterine contractions; treated by syntocinon infusion. If the twin
is retained for more than 30 minutes then deliver it by caesarean section if
head is high or instrumental if head is low.
2. Fetal distress: fetal heart-CTG
3. Haemorrhage: assess by observation
4. Cord prolapsed

The above 4 complications are treated as follows:

77
1. If the second twin is cephalic it should be delivered by forceps or Vacuum
extractor if the head is low, and by emergency caesarean section if the
head is high.

2. If the second twin is breech it should be delivered by breech extraction

(the only indication of breech extraction).

78
 GUIDELINES FOR NEAONATAL RESUSCITATION

Hospital delivery
Preparations:-

 Review the obsteric notes to identify any important factors (HTN, DM).
 Wash your hands, put on gloves and prepare the resuscitation area.
 Make sure any doors and windows, fans and conditionered are closed.
 Ensure there are enough warm towels.
 Check the gas supply and any delivery system[ bag/mask]
 Check that the suction works and is set appropriately with the right size
catheter.
 Ensure that airway adjuncts are available,oropharyngeal airways,
laryngoscope/torch.
 Check that equipment for intubation is available.
 Check venous access equipment and resuscitation.
 Check the clock.

Home delivery:
Preparations :-

 Two midwives should be present at birth if possible.

 Prepare for hospital transfer if needed(Multiple pregnancies, Preterm
deliveries, Fetal distress, Meconium staining, Previous scar, Primigravida,
Hypertension/ or bleeding, Trial of labour, Precious baby)
 Firm,suitable surface (possibly the floor)
 Temperature control (close the windows, doors and stop fans…etc)
 Stethoscope
 Timing (use your watch or a house clock)
 Ambu self inflating bag [500 mls bag]
 Suitable facemasks [size 00,0/1]
 4 towels

79
  Good ligth ,torch.
 Mucus extractor
 Disposable gloves.
 2 hats
 Sterile packs of cord scissors & umblical clamp
 Oropharyngeal airways (size 0,00, and 000)

THE STEPS:
 Dry & cover the baby
 Assess the situation
 Airway
 Breathing - Inflation breaths
 Chest compressions
 (Drugs)

Initial actions:
 Start the clock
 Dry the baby and then
 cover with warm dry towels

 Do you need help?

Assess:

o Colour
o Breathing
o Tone
o Heart rate
- Blue Pink
- Good tone
- Breathing regularly
- Fast heart rate

Dry and cover

Give to Mother

80
 - Blue
- Moderate tone
- Breathing inadequately
- Slow heart rate

Dry and cover

Open the airway
Inflation breaths?

- Blue or white
- Floppy
- Not breathing
- Slow or very slow heart rate

Dry and cover

Open the airway
Inflation breaths
Re-assess
Do you need help ?

Airway Management:
In the unconscious baby airway obstruction is usually due to loss of pharyngeal
tone not foreign material in the airway i.e. Position not suction.
• Hold head in neutral position
• Chin supporT
• Consider jaw thrust
• If no response, do inflation breaths (Five breaths, each sustained for 2-3
seconds at 30 cms of water pressure).
• If there is no heart rate response,
• check for chest movement

81
 • About 95% of babies for whom help is called will recover within a minute
or two once air enters the lungs.
• Mask inflation is nearly always effective
• Only about 1 in 500 appear to need intubation.
• Reassess:

o If the heart rate is slow and not improving do chest compressions.

o Do not start chest compressions until the chest is being inflated.
o If chest moving well, heart rate normal, baby still not breathing,
ventilate at ~ 30 breaths per minute.

Chest compressions:
• You want to move oxygenated blood from the lungs to the coronary
arteries, its not that far and won’t take long.
• Reassess
o Has the heart rate improved.
o If not :
 Check airway
 Check chest movement
 Check compressions

o If no response consider drugs:

 Sodium bicarbonate
 Adrenaline
 Dextrose
 (Volume - rarely)

What next ?
• Reassessment
• Temperature
• Blood sugar
• Parents
• Records
Poor outlook if :-
• No output at 15 minutes
• Or heart rate responds but not breathing regularly by 30 minutes.
82
 GUIDELINES FOR ANAESTHESIA FOR CAESREAN SECTION

 Communicate the degree of urgency to staff

 Immediate: Immediate threat to life of mother or fetus
 Urgent: maternal and fetal compromise that is not immediately life
threatening
 Early: No maternal and fetal compromise but needs early delivery.
 Elective: delivery timed
 The Pt should be transferred to theater and rapidly as possible
 Fetal monitoring should be Continued
 General anaesthesia is used for immediate C/S in most centres
 Urgent CS done under regional anaesthesia
 The time between decision and delivery shoud be less than 30 minutes if
the indication of CS is fetal distress.

Regional anaesthesia for CS:

- Initially was deriven by maternal preference.
- Regional is > 16 times safer than general anaesthesia.

Advantages of regional anaesthesia:-

o Improved safety for mother with minimal risk of requrgitation
and aspiration pneumaitis with is a fatal Complication.
o low risk of anaphylaxis
o The neonate is more alert promoting early bonding and breast
feeding
o fewer drugs one administered with less hangover than G.A.
o better post operative analgesia and early mobilization.
o both mother and husband can be present at delivery

 Although regional anaesthesia is safer, maternal refusal remains a

contraindication.
83
 It is reasonable to give a nervous mothers aclear explanation of advantages
and disadvantages, mothers should not be forced in to accepting regional
anaestheesia.
 Three techniques are available: Epidural, spinal and compined epidural,
spinal and compined spinal epidural .
 Epidural is most commonly used for women who already have epidural
analgesia in labour.
 Spinal is the most popular technique for elective CS.
 What ever technique is chosen, a careful history and approporiate
examination should be performed

 This should include checking :-

o Blood group and routine crossmatching of blood.
o U/S to establish the position of the placenta, low lying placenta
put the mother at risk of major haemorrhage particulary if
associated with previous scar .

 An explanation of the technique must be offered. Although CS under

regional anaesthesia become routine for anaesthetist, it is rarly routine for
the mother. Reassourane and support are important.
 The possibility of complications must also be mentioned.
 Pain during regional is now a leading cause of maternal litigation.
 Document all complications that are discussed Neonates are usually more
alert after regional than G.A.
 The speed of onset of sympathectomy that occurs with spinal, results in
greater fall in maternal cordiac output and blood pressure and may be
associated with amore acidatic neonate at delivery
 In conditions where sudden fall in after load is expected (mritral and aortic
stenosis), the speed of onset of spinal block can be slowed by:
1. Using inrathecal catheter to top-up doses.
2. Careful positioning during the onset of the block.
3. Using Combined spinal epidural:- give small dose for
spinal and top-up by epidural catheter.
 While a slow onset of block may be preferable in elective CS, a rapid
onset is necessary for emergency cases.
 Spinal anaesthesia provides abetter quality of analgesia and is quicker in
onset than epidural

84
Epidural:-

Advantages Disadvantages
Easy to-up labour epidural Slow onset Epidural
Large dose of local anaesthetics
Stable blood pressure Poorer quality of analgesia
Possible to top-up intra opratively

Post- operative analgesia

- Indications:
a. Patient who already have epidural catheter for labour analgesia
b. Specitic maternal disease (Cardiac disease) where rapid changes in
systemic vascular resistance might be problematic.

Technique:
 History, examination, explanation and concent.
 Ensure that antacid prophylaxis has been given.
 Establish 2 I.V lines by 2 large-bore cannulae
 Give 500-1000 ml of normal saline.
 Put the patient in sitting position.
 Wash your hands and wear sterile gloves.
 Wash the back of the patient by iodine solution.
 Inject 2-3 and of lignocaine 2% in L2 /L3 or L3/L4 vertebral inter
space by disposable syringe.
 Use toughy needle size 18.
 Insert acatheter
 Test dose (2 ml of heavy lignocaine).
 5-8 ml of 2% lignocaine with 1:200 000 adrenaline every 2-3 minutes
up to amaximum of 20 ml (0.5% of marcaine is better because it has
along duration).
 Opioid (fentanyl 0.1mg ) improves the quality of the block.
 Position the patientt in supine position with left lateral tilt or wedge.
 Give supplemental oxygen by face mask.

85
Spinal anaethesia:-

Advantages Disadvantages
Quick onset Single shot
Good quality Limited duration of analgesia
In adequate analgesia is difficult to correct Easy to
perform Rapid changes in blood pressure
&cardiac output.

 Spinal anaesthesia is the most commonly used technique for caesarean

sections. It is rapid in onset, produces adense block and with intra thecal
opioids can produce along acting post-operatine analgesia. How ever
hypotention is much more common than with epidural analgesia.

Technique:-
 History, examination, explanation and concent.
 Ensure that antacid prophy laxis was given
 Establish 2 I.V lines by 18 size cannulae. Injection of the drug.
 Prepare one unit of blood – more blood regiured for some cases
(bleeding).
 Check anaeSthetic machine, gases, intubation kits. Resuscitation drugs.
 Put the patientt in sitting position.
 wash your hands, wear sterile gloves.
 Wash the pt back by iodine solution.
 Use spinal needle size 24 or 25 gaguge.
 Puncutre the skin between L3 /L4 or L4 /L5
 Use 2-4 ml of local anaesthetic heavy lignocaine 5% or bupivacaine 0.5%.
 Use one ml of lignocaine to speed the onset use 2 ml of pupivacaine to
prolonged duration.
 put the patient in supine position with left lateral title to guard against
aorto-caval compression.
 Monitor the blood pressure, pulse, respiration, consciousness.
 Give I. M diclofenac Na+ 75 mg (contraindication)

 The most common complication is hypotension if occurs give: 6 mg of

ephedrine, increase rate of fluids infusion, oxygen by face mask.
86
 Delay surgery until BP stabilized.
 If hypotension is severe use diluted adrenaline
 Restrict fluids and omit the preload in pre/eclampsia and hypertensive pts.
If hypotension occurs, us ephedrine rather than fluids.

 Other complications include:

1. Total spinal anaesthesia: signs: apnea, cardiovascular
collapse, coma, fixed dilated pupils. It is common with
epidural.
Management:

o Intubate and ventilate with 100% oxygen.

Give fluids, adrenaline.
o Chest compersions
o After you stabilize the pt, wait until the drug
wears off
2. High spinal: There is difficulty in breathing, treatment:
give O2 by face mask, if servere intubate and ventilate
with 100% O2
3. Headache: treatment: diclofenac Na, paracetamal, opioids.
4. Epidural heamatoma and abcess: needs neurosurgical
decompression.
5. Neck and back pain: give analgesics
6. Cranial nerve palsy
7. Neurological deficit
8. Meningitis of encephalitis
9. I nadequate anaesthesia: incidence is 1-5% .
The majority should be identified before operation
commences.
Pre- operative in adequate block:-
 If no block develops, repeat spinal
 Use general if required.

Intra- operative inadequate block:-

Reassure and treat with:-
 N2O
 I.V opioids

87
  Surgical administration of local anaesthetics
 General anaesthia.

Contraindications of regional anaesthesia.

Absolute:
- Patient refusal
- Allergy to local anaesthetic
- Severe aortic or mitral stenosis (fixed cardiac output)
- Infection at the site of injection
- Anticoagulant drugs
- bleeding disorders
- increased intra-cranial pressure

Relative:
- Neurological disease (medico–legal) contraindication)
- Back abnormality (difficult block)
- Hypovalaemia (Correct first).

General anesthesia:-
- Elective G.A is now un-common
- Major complications include: difficult intubation, regurgitation and
aspiration of gastric content (aspiration preumonitis).

- Indications for G.A:-

o Maternal request
o Urgent surgery (expert can do regional)
o When regional anaesthesia contraindicated.
o Failed regional anaesthesia
o Additional surgery planned at the same time as caesarean
section

88
Technique :-
 History, examination-airway assessment
 Elective - Antacid prophylaxis: Ranitidine 150 mg 12 hrs and 2 hrs before
surgery
 10 mg metocloperamide orally 2 hrs before surgery
 30 ml sodium citrate immediately before inducation orally
 Emergency: 50 mg Ranitidine I.V immediately before surgery (proton
pump inhibitor is an alternative )
 10 mg metocloperamide I.V immediately before surgery
 30 ml Na citrate immediately before surgery
 Start appropriate monitoring.
 Position supine with left leteral tilt
 Establish 2 I.V lines by connulae size 18
 Start infusion of normal saline (special care with diabetes, hypertension)
 Rapid-sequence induction:-
 Anticholineregic 10 mg atropine or hyosine
 Induction agent: thiopentone, ketamine or propofol
 suxamethonium 100 mg
 Intubation
 Pancuronium 4-6 mg or atracurium 30-50 mg.
 N2 O,O2, halothane 0.5%
 At delivery: give I.V oxtocin 20 IU bolus
 Then infusion of 30-50 IU
 Give opioid (25 mg pethedine)
 Stop halothane (uterine relaxation)
 Give 75 mg diclofenac

Effects of G.A on the fetus):-

- Most anaesthetic drugs cross the placenta
- Opioids given before delivery depress the fetus.(reversed by naloxone).

Special Cases
Placenta praevia:- prepare 2-8 units of blood

89
  G.A is preferable because bleedings and hypotension are major
complications and it is difficult to control hypotension which
aggravated with sympathectomy in regional anesthesia
 Do not forget surgical methods of controlling hemorrhage:
bimanual compression of the uterus, ligatin of internal iliac artery,
temporary compression of aorta
 Avoid drugs that cause hypotension: propofol, halothane.
 Prepare vaso pressors: ephedrine, adrenaline
 Fluids: colloids, crystalloids .

Massive obstetric haemorrhage:

 If major haemorrhage requiring surgery, do not delay operation
until crossmatched blood is available
 Call for help
 Give O2, If laryngeal reflexes are abtunded intubate
 Insert 2 large bore cannulae and take blood for crossmatching
 Give fluids: colloids & crystalloids.
 If blood loss is 2-3 L give O-ve blood
 Monitor the patient: urine output, BP, pulse
 Treat the cause of haemorrhage: if surgery required do G.A.
 If haemorrhage continue further equipment including warning
devices and rapid transfusion devices (3 way cannula) needed.
 Correct coagulopathy: platelets, F.F.P and cryoprecipitate
 Continue care in I.C.U
 Uterotonics: oxytocin, ergometrine, PG

Pre-eclampsia:
 G.A. if there is thrombocytopenia
 Recent studies should that pre-eclampitic mothers are less prone to
hypotension and no difference in out come between spinal and
epidural. spinal produce better analgesia
 Reduced preload
 Give ephedrine in small doses ( effect)
 Avoid NSAID.

90
Eclampsia:
 Management is aimed at immediate control of the fit and
secondany prevention of further fit
 Immediate management :-
 Airway (left lateral position with jaw thrust)
 Bag and mask ventilation
 Circulation (I.V access and meassure BP
 Avoid aortocaval compersion
 Control fit with Mg so4
 Prevent fit with Mg so 4 infusion
 Eclampsia is not an indication for emergency CS(stabilize the Pt
first
 G.A ????

91
 GUIDELINES FOR THE MANAGEMENT OF ANTEPARTUM
HAEMORRHAGE (APH)

1. Introduction:
Antepartum haemorrhage is vaginal bleeding from 28 weeks (24) gestation
and before delivery of the baby. It is one of the leading causes of maternal
mortality and morbidity and operative intervention. Perinatal outcomes
include a higher rate of pre-maturity and perinatal death.
The causes of APH are: Placenta praevia, Abruption, uterine scar
disruption, local causes, vasa previa and a large group of undetermined
causes.
Placenta previa is the placenta which lies wholly or partially in the lower
segment (minor =not reaching os or just reaching edge of os.
Major=covering os.) the main risk factors are: previous caesarean section,
previous uterine instrumentation, high parity, old age and multiple
pregnancy.
Placental abruption is premature separation of a placenta from the uterine
wall leading to retroplacental clot and eventually death of fetus. It could be
concealed or revealed. The bleeding in the myometrium results in
couvelaire uterus and PPH. It may be complicated with coagulopathy. The
main risk factors are: hypertensive disease, trauma, over distension of
uterus and a past history of abruption. These guidelines describe the
management of placenta previa and abruption.

2. Management of large APH

2.1. Placenta praevia:

2.1.1. Diagnosis:
- Painless vaginal bleeding, may be post coital, recurrent.
- The general condition of the patient correlates with the
amount of external bleeding
- Pallor, tachycardia, hypotension shock
- Soft abdomen, malpresentation, high head, fetal heart usually
heard.
- Ultra sound: Diagnosis of placenta previa. Posterior placenta may
be difficult due to shadowing of presenting parts.
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2.1.2. Treatment
- Call for help. Inform consultant. Initiate resuscitation.
Left lateral tilt. Check airway and give 100% oxygen by
mask.

- 2 wide intravenous canulae (14G) and take blood for CBC and
crossmatch 6 units.

- Give 0.9% saline as rapidly as needed while awaiting blood.

- Give Haemagel as rapidly as needeing while awaiting for blood

after taking blood for grouping and crossmatching. Observe for
allergy.
- Once available give warm blood as much and as rapidly as needed
(Crossmatched takes 1 hour, Blood type specific takes 15 minutes,
ORh negative immediately).

- Intensive monitoring throughout and keep the patient warm

Indwelling catheter hourly urine output.
Pulse blood pressure, temp and oxygen saturation.

- Immediate caesarean section

- To be done by consultant (s)
- Under general anaesthesia
- Vertical abdominal incisions
- If bleeding from placental bed attempt suturing and if
not controlled do hysterectomy, sooner rather than later.
- If placenta is adherent do hysterectomy

- Watch for PPH which is inevitable.

93
2.2. Placenta Abruption
2.2.1 Diagnosis
- Pain. The hallmark symptom. continuous (no pain or
tenderness between uterine contractions in normal labour)

- Vaginal bleeding: Amount of external bleeding does not

correlate with the general condition of patient (minor vaginal
bleeding and patient is shocked due to retroplacental clot). The
blood is usually dark. The amniotic fluid is bloody.
Bleeding may be concealed

- There may be a history of hypertension or trauma

- Pallor, tachycardia, hypotension, shock

- Abdomen tender +rigid (Board like rigidity) No evidence of

contractions and relaxation, continuous rigidity.

- Fetal heart: usually absent, could be heared and normal or

bradycardia.

- Diagnosis is clinical U/S may demonstrate retroplacental colt.

2.2.2 Treatment
- Call for helps; inform consultant initiate resuscitation
Left lateral tilt
Check airway and give 100% oxygen

- Get I.V access

2 intravenous lines (14G) and take blood for CBC,
clotting and crossmatch 6 units.
Blood in a tube for clothing
 May do: fibrinogen > 150mg /100ml
 Platelets low

94
- Give 0.9% saline as rapidly as needed while
awaiting blood.
- Give haemagel while awaiting blood
- Once available give warm blood as much and as rapidly as
needed (crossmatch takes I hour, blood type specific takes 15
min, ORh Negative immediately.

- Intensive monitoring throughout and keep patient warm.

o Urinary catheter-hourly measurement
o Pulse, BP, temp oxygen saturation (every 15 minutes).

- If there is evidence of coagulopathy (blood not clotting in the

tube or biochemical evidence, Give the following before C/S or
ARM:
- Warmed fresh blood
- Cryoprecipitate
- Platelet are rarely needed.

- If fetus is alive deliver by immediate caesarean section by the

senior person available (consultant/ regsitrar).

- If the fetus is dead:

o Deliver by immediate C/S if the abruption is major.
o Deliver by immediate C/S is there is an added factor e.
g previous c/s, contracted pelvis
o If abruption is not major induce by ARM + syntocinon
(ARM in the theatre) and do C/S if:
 Bleeding continues or brisk bleeding
 Failure of progress (not more than 12 hours)
 In all cases delivered vaginally or by caesarean
section WATCH for PPH and treat promptly.
PPH is inevitable.
 1/3 of patients with Abruption and dead fetus
develops coagulopathy. Patients with abruption
and alive fetus rarely develop coagulopathy.

95
3. Management of small APH:
- History + examination and exclude large APH or placental
abruption.

- Admit all patients in labour room-even those with slight

bleeding-and keep in labour room for at least 24 hours. Observe
hourly: pulse, BP, abdomen (contractions and rigidity), fetal
heart, vaginal bleeding. CTG: for fetal heart and contractions.

- Vaginal examination is strongly contraindicated.

- Intravenous line-large canula (14G).

- Take blood for CBC, clotting and crossmatch 6 units.

- Inform consultant
- Do U/S
o If there is placenta praevia, deliver by caesarean section
if the gestational age is ≥ 36 weeks or the size of baby is
good
Give Dexamethason before delivery.

o If there is placenta praevia and gestational age is > 36

weeks plan expectant management:
 Keep in hospital till delivery even if the placenta
praevia is minor and the bleeding is slight
 12 hourly observation: Pulse, BP, fetal heart,
vaginal bleeding
 Serial u/s weekly.
 Deliver if: she goes in labour, develops severe
bleeding or recurrent bleeding, IUFD or IUGR,
reaches 38 weeks.
 Severe bleeding=immediate C/S
 Labour: C/S for major placenta praevia
and ARM + syntocinon for minor
placenta praevia if there is no added
factor e.g scarred uterus or
grandmultipra.
96
 
Reaches 38 weeks deliver by c/s if
major placenta praevia and induction if
minor placenta praevia provided that
there is no added factor e.g scarred
uterus or grandmultipara or breech.
 IUGR: deliver by C/S
 IUFD: induce after 3 weeks if she does
not go in labour spontaneously
Note: All cases of caesarean section MUST be done by a consultant/ registrar.

If the placenta is fundal:

o Do speculum examination for the diagnosis of local
causes (cervicitis, polyp, carcinoma, ectropion) and
cervical dilation.

o If no local cause and patient not in labour: Diagnosis of

placenta praevia or abruption is never established.
These patients generally exhibit no maternal or fetal
compromise. Vaginal bleeding resolves without
explanation, no tenderness and prognosis is good.
Therefore observe in hospital and wait for spontaneous
vaginal delivery.
Vasa praevia:
o Fetal blood vessels traversing presenting membranes
and is associated with abnormal insertion of fetal
vessels into the membranes rather than placenta
(ie.Velamentous insertion).

Diagnosis:
- Bleeding coincide with rupture of membranes spontaneous or
artificial.

- Apt test for fetal haemoglobin:

(sample of blood from vagina+tab water+Na OH a pink colour
indicates fetal haemoglobin. Adult haemoglobin is brown.
If Apt test is positive for fetal haemoglobin deliver immediately
by C/S.

97
GUIDELINES FOR THE MANAGEMENT OF PRIMARY POSTPARTUM
HAEMORRHAGE (PPH)

1. Introduction:
Primary Postpartum Haemorrhage (PPH) is defined as: Blood loss from
the birth canal more than 500ml after spontaneous vaginal delivery (SVD)
and more than 1000 ml after caesarean section within 24 hours after
delivery.
PPH is the most common cause of maternal death worldwide. Uterine
atony is the commonest cause of primary PPH. Other causes include
trauma, placenta and coagulopathies.

The specific causes of PPH may be remembered the mnemonic " THE 4 T’S"

T: Tone :Atonic uterus : 7S0%

T:Trauma :Episiotomy, perineal laceration, vaginal lacerations,
ruptured uterus, uterine inversion, pelvic haematom 20%
T:Tissue :Retained placenta, Retained products,
adherent placenta : 10%
T: Thrombin :Coagulopathies: 1%

Risk factors for PPH:

- History of PPH, grandmultipara, APH, previous caesarean section,
multiple pregnancy, hydramnios, prolonged and obstructed labour,
caesarean section, forceps, ventous, breech extraction, induced and
augmented labour.

However PPH may occur in women without identifiable clinical or historical risk
factors. It is therefore recommended that active management of the third stage of
labour be offered to all women during childbirth.

Management of third stage:

- Expectant - physiological: Wait for signs of separation of placenta
(uterus globular, mobile and ascend to the level of umbilicus,
98
 shortening of cord, gush of blood, feeling placenta in the vagina) and
allowing placenta to deliver spontaneously or by controlled cord
traction CCT. Then give oxytocin (0.25 mo ergometrine intramuscular
or 5 IU syntocinon intramuscular. Syntocinon infusion 40 IU in 500 ml
saline 30 drops/min for at risk patients.

- Active management:
RECOMMENDED FOR ALL WOMEN Oxytocin given at the time
of delivery of anterior shoulder with early cord clamping and cutting
and controlled cord traction. 5 IU syntocinon intramuscular at the
delivery of the anterior shoulder or immediately after delivery of baby
and then deliver placenta by CCT 2-3 minutes after syntocinon.
Or 0.25 mg Ergometrine intramuscular at the delivery of anterior
shoulder or immediately after delivery of baby and deliver placenta by
CCT 2-3 minutes later.

- PPH is a leading cause of maternal death and an important cause of

maternal morbidity: anaemia, Sheehan syndrome, risks of blood
transfusion, coagulopathies and acute renal failure. The complications
of PPH could be reduced by: correction of anaemia antepartum, review
risk factors and anticipate PPH, episiotomy only if indicated, active
management of third stage, observe mother closely for 2 hours after
delivery.
Even with those efforts, some women will still require treatment for
excessive bleeding. Effective treatment of PPH often requires
simultaneous multidisciplinary interventions (medical, mechanical,
invasive, non surgical and surgical procedures).

General Objectives:
These guidelines have been prepared to promote and facilitate
standardization and consistency of practical using multidisciplinary
approach to treat primary PPH so as to reduce maternal mortality and
morbidity.

99
General Approach to women with Primary PPH
1. Assess blood loss visually. DO NOT UNDERSTIMATE. DO NOT
DELAY TREATMENT UNTIL VITAL SIGNS DETERIORATE:
TAKE PATIENT TO THEATRE ERRLY

2. Vital signs; pulse, BP, respiratory rate

3. Resuscitation (oxygen, saline, blood).
4. If placenta is not delivered
- Message uterus
- Oxytocic drugs
- Catheterization
- CCT and if failed:
- Take patient to theatre and do manual removal of
placenta in the theatre

5. If placenta is already delivered or delivered manually, Treat atony.

6.Then do Exploration and stitch tears and laceration
7. Laparotomy +surgical treatment: sooner rather than later.
8.Coagulopathy: give fresh blood

1.2.3. Assessment and resuscitation

- Pallor
- Pulse: tachycardia
- Blood pressure: hypotension
- Amount of bleeding by OBSERVATION
- Signs of shock.

- Call for help. Check airway and give 100% oxygen by

mask/Ambo bag .

- Fix 2 large bore I.V canulae 14G-16G

- Take blood for: CBC, clotting and crossmatch at least 6 units.
- Give intravenous fluids in the form of normal saline (crystalloid) and
plasma expander (colloid) as rapidly as needed awaiting blood.

- Transfuse blood as much and as rapidly as needed.

o Blood grouping takes 15 minutes
o Crossmatching takes one hour
100
 o ORh Negative: immediate. Transfuse if available.

- Intensive monitoring throughout and keep the patient warm

o ¼hourly: pulse, BP, temp and Oxygen saturation
o Insert follyُs catheter and monitor urine output.
o Observe blood for clotting and if clotting disorder present give:
fresh blood, fresh frozen plasma, cryoprecipitate.

4. If the uterus is not contracted (uterine atonia) COMMENST CAUSE:

- Uterine massage (rub up the uterus) and bimanual compression .

- Oxytocic drugs
o Intravenous ergometrine 0.5 mg (hypertension, vomiting).
o Intramuscular syntometrine ergometrine 0.25 mg + 5 IU
syntocinon).
o Syntocinon 10 IU intravenous.
o Syntocinon 40 IU in 500ml normal saline, 30 drops/minute over 4
hours (80 milliunits per minute) (water intoxication with extended
use)
o Misoprostol 800 micrograms into the rectum (suppositories).

- Then if needed:
Carboprost 250 microgram intramuscular. Can be repeated every 15
minutes. Maximum dose 2 mg. can be given intramyometrial. Contra-
indicated in cardiac, renal, pulmonary and hepatic disease.

- If placenta is not delivered:

o Try Controlled Cord Traction (CCT)
o If CCT fails take the patient to the theatre and remove placenta
unde general anaesthesia-ketamine-try CCT before manual
removal.
o If still bleeding do exploration in the theatre under general
anaesthesia. If there is no evidence of trama and patient is still
bleeding-uterine atonia manage the patient in the following
sequence:

101
 - Uterine pack with big gauze or hydrostatic ballon filled with
300-500ml water, if available.
- If still bleeding:
o Laparotomy (for diagnosis and treatment): DO NOT
DELAY.
o If bleeding is out of control and the anaesthetist needs
to stabilize the patient, try aortic compression.
o Uterine artery ligation + ovarian artery ligation
o B-Lynch brace suture using a straight needle and
chromic cat gut. It exerts longitudinal lateral
compression to the uterus combined with a
tamponade.
- If still bleeding,
o Subtotal hysterectomy: sooner rather than later.
o Embolization of uterine artery may substitute subtotal
hysterectomy If available.

5. If the uterus is contracted or if uterine atonia is not respondining to

treatment:
EXPLORATION IN THE THEATER UNDER GENEAL ANAESTTHIA
(KETAMINE) WITH GOOD LIGHT AND EVERYTHING READY FOR
LAPAROTOMY
- Put a big gauze high up to be able to visualize perineum and vaginal
lacerations
- Perineum, episiotomy, vagina, ligate bleeding vessels and stitch tears and
lacerations with continuous chromic or VicryI.

- Cervix:
- Examine carefully using 3 ovum forceps.
- Place the first forceps at 12 O'clock and keep till the end of inspection.
- Put the second forceps at position 3 O'clock and examine 12-3 O'clock area.
- Then put the third forceps at position 6 O'clock and examine 3-6 O'clock
area.
- Then put the second forceps at position 9 O’clock and examine 6-9 area.
- Then examine 9-12 O'clock area
o Stitch any tear with chromic catgut
o If tear extends to uterus perform lapratomy
102
 - Uterus:
o Insert the right hand inside the uterus and support uterus by the left
hand.
o Remove any placental tissues or membranes
o Feel for tears and perforation.
o If any tear or perforation, perform laparotomy and do repair or
hysterectomy if needed according to the patient parity and degree
of tear.
o If acute inversion is diagnosed, correct it.

Coagulopathies (T-thrombin)
- Most important are: placental abruption, severe pre-eclampsia and amniotic
fluid embolism, IUFD
- Other causes: idiopathic thrombocytopenic purpura, von will brand's
- Excess bleeding can deplete coagulation factors
- Diagnosis:
o Not responding to usual measures to treat APH
o Not forming blood clot
o Oozing from puncture sites
o Abnormal PT (INR), fibninogen level > 100 mg/100ml, D-dimer,
low platelet

- Treatment:
o Transfuse fresh blood and blood products: platelet and fresh
frozen plasma
o If bleeding continues do subtotal hysterectomy.

103
GUIDELINES FOR THE MANAGEMENT OF RETAINED PLACENTA
WITH NO POSTPARTUM HAEMORRHAGE

1. Introduction:

One of the Millennium Development set by the United Nations in 2000 is to

reduce maternal mortality by three-quarters by 2015. If this is to be achieved,
maternal deaths related to postpartum haemorrhage must be significantly
reduced. Appropriate medications, training in relevant procedures and
guidelines on the management of retained placenta will provide the foundation
for reducing maternal mortality as it is one of the leading causes of PPH.
These guidelines describe the management of retained placenta

2. Diagnosis:
Failure of delivery of placenta after half an hour of delivery of the baby.

3. Causes of retained placenta: full bladder, morbid adherent placenta,

constriction ring and adherent membranes

Risk factors for invasive placenta:

- Previous caesarean section
- Previous placenta praevia
- Previous dilatation and curettage
- High parity
- Previous retained placenta .

4. Complications
- Postpartum haemorrhage: MOST IMPORTANT
- Sepsis, postpartum collapse and Psychological effect.

104
Management:
- Fix 2 intravenous canullae (14G-16G) and take blood for
CBC, clotting and crossmatch 6 pints of blood.

- Give normal saline infusion and once blood is available

give blood.
- Catheterize the bladder
- Try controlled cord traction AFTER MAKING SURE
THAT THE UTERUS IS WELL CONTRACTED.

- Give syntocinon 40 IU in 500 ml saline (30 drops/minute -

80 milliunit per minute) in combination with controlled
cord traction.
- Ergometrine is not recommended as it may cause tetanic
uterine contractions, which may delay expulsion of
placenta.

- If controlled cord traction fails, deliver the placenta by

manual removal of placenta under general anaethesia in the
theatre.

Manual Removal of the Placenta under GA

- Patient in lithotomy position
- General anaesthesia. Ketamine
- Catheterize the bladder
- Try controlled cord traction
- If failed:
o Introduce the right hand inside the uterine cavity
o Support the uterus with the left hand.
- Identify the cleavage plane between the placenta and the
uterus. Start separation of the placenta from cleavage area

105
 using the index finger with its medical border and move
anti clockwise till complete separation.

- Deliver the placenta intact with controlled cord traction.

- Examine the placenta to ensure that it is complete and if
not, remove the remaining part manually in pieces.
- Give ergometrine and continue syntocinon infusion for 4
hours.
- Keep in labour room for 4 hours.
- Observe ½ hourly for 4 hours (pulse, BP, uterus, vaginal
bleeding). Then transfer to post-natal ward and same
observation 4 hourly for 24 hours.
- Give I.V third generation cephalosporin and I.V
metronidazole for at least 72 hours.
- Observe for PPH.
- If the cleavage plane cannot be identified and placenta
could not be separated (placenta accrete, increta or
precreta), do:
- Emergency subtotal hysterectomy if the patient has
children.

OR: Remove the placenta by pieces using ring forceps and

blunt curette if the patient has no children This procedure is
associated with severe bleeding and sometimes perforation of
uterus.

Therefore: if the bleeding cannot be controlled, do emergency

subtotal hysterectomy.

Note:
- Total placenta accreta may not bleed significantly until
attempts are made to deliver it in pieces. Partial placenta
accreta usually presents as retained placenta with PPH,
because only part of placenta seperates and the uterus
cannot contract.

106
 - Most women with adherent placenta will require emergency
subtotal hysterectomy.

- Diagnosis of adherent placenta is typically not made until

the time of manual removal of placenta.

- Sophisticated ultrasound scanning could diagnose adherent

placenta antepartum.

Management of Retained Placenta with Postpartum Haemorrhage (PPH)

- Same treatment of Primary PPH
- If placenta could not be delivered by controlled cord
traction, DO NOT WAIT FOR 30 MINUTES, MANUAL
REMOVAL OF PLACENTA IN THE THEATER UNDER
GENERAL ANAESTHESIA IMMEDIATELY.

107
 GUIDELINES FOR THE MANAGEMENT OF RUPTURED UTERUS

1. Introduction:
Ruptured uterus is a serious obstetrical complication which occurs almost always
during labour. It claims a significant portion of maternal deaths in the Sudan. It is
also associated with injuries to bladder and ureters, hysterectomy and fetal death.
It is a condition which could be anticipated and prevented, even though an
obstetrician should have optimum skills to diagnose and treat it even if it is
unanticipated. Essentially it is a problem of internal haemorrhage and as such its
management includes: prompt diagnosis, urgent resuscitation and laparotomy,
repair or more commonly hysterectomy. SPEED IS REQUIRED.
These guidelines describe the main causes/risk factors, methods of diagnosis and
techniques of surgical management.

2. Causes/Risk factors:
2.1. Obstructed labour in a multiparous -Malposition and
malpresentaion, big baby, hydrocephalus etc. Obstructed
labour in a primigravida rarely cause ruptured uterus unless
the uterus is congenitally malformed
2.2. Scarred uterus
Previous caesarean section is a very common aetiology of ruptured
uterus, especially if more than one scar, upper segment.
Hysterotomy, scar of a perforation, previously repaired ruptured
uterus.
2.3. Syntocinon infusion in a multiparous
2.4. Forceps, vacuum extractor, breech extraction, internal version.
2.5. Grandmultipara
2.6 Manual removal of placenta especially if adherent

108
3.Types of ruptured uterus:
- Traumatic:
Rupture is shattered, edges necrotic
- Dehiscence of scar:
previous scar gaping, edges are not necrotic
- Complete: Involves myometrium and visceral
peritoneum usually placenta and fetus are
outside the uterus.
- Incomplete: Involves myometrium but visceral
peritoneum intact-diagnosis is not easy.

4. DIAGNOSIS:

4.1. Anticipate ruptured uterus if the patient has one of the above risk
factors.
- Close monitoring and timely intervention before the
rupture (Tachycardia, prolonged /obstructed labour,
fetal distress, tetanic contractions)
- Do not wait for signs of ruptured uterus; bulging at scar
and vaginal bleeding.
- The diagnosis is clinical.
4.2. Symptoms:
- Severe continous abdominal pain, cessation of uterine
contractions, vaginal bleeding (usually not heavy),
shoulder tip pain.
4.3. Signs
 Pallor, tachycardia, hypotension, shock
 Abdomen: Distended, abnormal contour, rigidity
and guarding, tenderness, fetal parts easily felt
(only early, late may be difficult due to
haemoperitoneum), high presenting part, absent fetal
heart
 PV: vaginal bleeding, loss of station
4.4. Differential diagnosis: Abruption

109
5. MANAGEMENT:
5.1. General
 Shout for help and urgently mobilize all personnel
 Perform rapid evaluation of patient - base line: pulse, BP, respiratory
rate, temperature.
 Give 100% oxygen by face mask
 Insert 2 wide bore I.V canulae (14-16G)
 Send blood for: CBC, clotting and crossmatch 6 units of blood.
 Give iv normal saline (or Ringer’s lactate) as available
 Monitor 1/4 hourly: Pulse, BP and urine out put via an indwelling catheter.
 Obtain informed consent for laparotomy and hysterectomy

5.2. Laparotomy; Repair or Hysterectomy

- Prophylactic antibiotics: 2 g ampicillin I.V or cefazoline 1g I.V.
- Laparotomy under general anaethesia
- Midline incision
- Deliver baby and placenta
- Infuse 40 I.V syntocinon in 500 ml normal saline, 30 drops per minute.

- Lift the uterus out of the pelvis in order to note the extent of the injury.

- Remove clots and examine uterus for site(s) of rupture

- Examine both the front and back of uterus

- THEN PERFORM REPAIR OR HYSTERECTOMY

REPAIR:
- If uterus can be repaired with less operative risk than hysterectomy and
bleeding could be controlled, and edges are not necrotic.
- Repair involves less time and blood loss than hysterectomy
- Usually possible in dehiscence of scar than traumatic rupture
110
- The tear (s) is not too extensive for repair

- Technique:
 Place a bladder retractor over the pubic bone
 Hold the bleeding edges with Green Armytage; separate the
bladder from the uterus. Repair the uterus two layers using
continous chormic cat gut No 2 or Vicryl No 2.
 If the rupture extends through the cervix and vagina:
Mobilize the blader at least 2 cm below the tear. Then place a
suture 2 cm above the lower end of the cervical tear and keep
traction on the suture to bring the edge angle of the tear into view
and repair it.

 If the rupture is lateral through the uterine artery; ligate the injured
vessels, try to identify the ureter before ligation (THIS IS NOT
ALWAYS POSSIBLE, PRIORITY TO CONTROL THE
BLEEDING.

 If the rupture is in the broad ligament (broad ligament haematoma),

clamp, cut and tye off the round broad ligament, drain haematoma
and ligate bleeding vessels.

 Inespect carefully for bleeding. If bleeding is not controlled

proceed FOR HYSTERECTOMY.

 If the bladder is injured:

o Identify the extent of the injury
by grasping each edge of the tear
with a clamp and gently
stretching it. Determine if the
injury is close to the trigon
(ureters, urethra)
o Dissect the bladder off the lower
uterine segment.
o Free 2 cm circle around the tear

111
 o Repair the tear in 2 layers; the
bladder mucosa and the bladder
muscle, with continous 3-0
chromic cat gut or 3-0 Vicryl.
o Ensure that the sutures do not
enter the trigon area .
o Test the repair for leak by sterile
normal saline through the
catheter and if there is a leak
remove the suture and repair
again.
o Keep the catheter for 7-10 days
o If the tear involves the trigon call
a urologist surgean.

 Perform tubal ligation if she has children

 Fix a drain and close the abdomen
 Remove the drain when it stops draining usually 48 hours
 Postoperative:
4 hourly pulse, B.P and bleeding (external or internal) Triple antibiotics
(Gentamycin 5 mg/kg body weigh every 24 hours, metronidazol 500 mg
infusion 8 hourly and ampiclox 500 mg 8 hourly.

HYSTERECTOMY:
 perform hysterectomy if :
o The tear (s) is too extensine for repair
o The edges are necrotic
o The bleeding could not be controlled
o The patient is a multiparous with enough
children.

 Usually subtotal hysterectomy Rarely total hysterectomy is indicated if the

cervix or vagina are involved.

 In case of massive bleeding the assistant press over the aorta in the lower
abdomen

112
 Technique:
- Lift the uterus out of the abdomen
- Clamp and cut the round ligament and ligate it.
- Double clamp and cut the tube, the ovarian ligament and the broad
ligament. Then ligate the pedicles
- Devide the posterior leaf of the broad ligament and push
downwards towards the uteroscard ligament.
- Open the anterior leaf of the broad ligament and incise to the point
where the bladder peritoneum is reflected to the lower uterine
surface in the midline
- Dissect bladder downwards especially laterally to push the ureters
away
- Locate the uterine vessels on each side and double clamp and ligate
them at a 900 angle, using chromic cat gut No2. or vicryl No 2.
- Amputate the uterus above the level where the uterine vessels are
ligated using scissors.
- Close the cervical stump with continous 2 layers using chromic cat
gut No 2 or Vicryl No 2.
- Inspect carefully for bleeding
- Fix a drain
- If bladder is injured repair as described above
- Postoperative: same as described above.

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 GUIDELINES FOR THE MANAGEMENT OF ACUTE INVERSION OF
THE UTERUS

Introcution:
 Serious and life-threatening third stage emergency.
 The earlier the intervention, the more chance of success.
 The main features of uterine inversion are shock out of proportion to blood
loss and bradycardia due to increase vagal tone.
 Diagnosis:
- Whole uterus outside the vulva – easy to diagnose.
- Vaginal examination will reveal a mass in the vagina and uterus can
not be felt above the symphysis.
 The main risk factors are: CCT when the uterus is not contracted or fundal
insertion of the placenta.

General objectives:
To eliviate the effect of the combination of hypovolumia, blood loss and
nurogenic shock as quickly as possible to safe rhe mother life.

Management:
1. ABC
o A: Air way. Maintain as level of conciousness require.
o B: Breathing: 100% oxygen by facemask.
2. Treat the patient in the theatre.
3. Insert two big bore canulae (14-16 G).
4. Send blood for CBC clotting and crossmatch 4 pints of blood.
5. Give adequate IV fluid, saline rapidly.
6. Give at least two bints of cross matched blood.
7. Atropine 600 microgram I.V if the heart rate is > 60 beat/min.
8. Give 100 mg of pethidine or 15 mg of morphine.
9. Give I.V antibiotics, third generation cephalosporins.
10. Administer general Anaesthia – Ketamine.
11. Epinephrine, 1:1000 in a dose of 0.3-0.6 ml intramuscular may be needed
to relieve uterine spasm.
12. Avoid to give oxytocic drugs before complete correction and if
Syntocinon is running stop it.

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13. Monitor hourly, pulse, BP for the first 4 hours then 4hourly for 24 hours.
14. correction:
- Early replacement:
When inversion is attended or recognized early before the inverted
corpus is trapped, replacement often can accomplished by manual
compression and insertion.

- Manual replacement:
The part coming last is replaced first. Stat posteriorly. Finally replace
the fundus. Give ergometrine or cyntocinon. Keep the hand in the
cavity till the uterus is well contracted.

IF FAILUED
- Hydrostatic maneuver of Osolvan: 3 litres of warm normal saline
run the fluid under gravity from a height of 2 meters, maintaining a
seal manually at the introitus.
Fill the vaginal with large amount of worm saline fluid till complete
correction, the reduction is usually achieved in 5-10 minutes. Give
oxytocic drug. Massage the fundus. Release the water gradually.

IF FAILUED
- Abdominal operative procedure:
Haultain technique:

Do a longitudinal incision of the wall of the uterus, then

withdrawal of the fundus of the uterus and then suture the uterine
wall.

IF FAILUED
Hysterectomy

- Vaginal operative procedure:

Spinelli technique:
Transect the cervix anteriorly, replace the fundus from below and
suture the cervix.
Kustner technique:
Transect the cervix posteriorly, replace the fundus from bellow and
suture the cervix.

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 GUIDELINES FOR THE MANAGEMENT OF THIRD & FOURTH
DEGREE PERINEAL TEAR:

Rational:
 Immediate early intervention carries les morbidity.

General objective:
To identify and treat maternal injuries complicating vaginal delivery.

Details of guidelines:
Prevention:
1/ Allow time for adequate perineal thinning.
2/ Avoid an operative delivery (forceps or vacuum).
3/ Avoid routine episiotomy.
4/ Oil massage of the perineum in the last weeks of pregnancy in primigravidae.
5/Supprot the perineum during delivery.
6/ Worm soaks of the perineum.

Diagnosis (classification)

DERGEE DISCRIPTION
FIRST Laceration of the vaginal mucosa and/or the perineal
body
SECOND The above + deep subcutaneous tissue
INCOMPLETE THIRD The above +capsule and part of the anal sphincter
muscle
COMPLETE THIRD The above + complete anal sphincter muscle
FOURTH The above + laceration of the rectal mucosa

MANAGEMENT

When 3rd or 4th degree perineal tear is diagnosed,

Or when there is excessive bleeding from an episiotomy,
Or when there is bleeding from a repaired episiotomy
Do the following measures:
1. Secure big intravenous lines and give fluids, normal saline.
116
2. Prepare blood.
3. Take the patient to the theatre and put her in lithotomy position under good
light.
4. Start prophylactic antibiotic, third generation cephalosporins.
5. Anesthesia:
A. Pudendal block.
B. Local infiltration.
C. Epidural
D. If anesthesia not adequate add inhalation or intravenous analgesia.
6. Create an excellent field by the addition of the assistant’s retraction and a
vaginal pack placed in the upper part of the vagina, or by the use of gelpi
retractor. Examine for button hole defect in the rectal mucosa, by elevation
of the anterior rectal wall into the vagina
7. Use chromic cat gut No.000, or vicryl No.00.
8. Repair of the rectal mucosa:
Start 0.5 cm above the apex. Do interrupted sutures 0.5 cm apart and keep
the knot towards the rectum. The suture should be carried beyond the anal
verge onto the perineum by one stitch.
9. To decrease the dead space and build up the rectovaginal septa take 3 to 4
interrupted or running sutures into the internal sphincter and rectovaginal
fascia. Do not enter the rectal lumen.
10. Repair of the anal sphincter:
Identify the two ends of the sphincter and grasp them by two Allis clamps
and bring them anteriorly and medially. The sphincter is approximated by
using several Vicryl No. 00 careful interrupted sutures. The first suture is
placed in the posterior part in the bottom. This stitch must be supported by
at least one cm of the fascial capsule. This is followed by interrupted
sutures at the front, back and top of the sphincter. Complete re-
approximation of the sphincter is achieved by placing suture wherever
necessary. Avoid figure of eight sutures.
11. Approximate the perivaginal fascia by interrupted or running No.00
Vicryl.
12. closure of the vaginal mucosa:
Identify the apex. Place the first suture one cm above the apex and close
the vaginal mucosa by running (locked or unlocked), down to the level of
the hymeneal ring.
13. Closure of the dead space below the vaginal mucosa: By several
interrupted one or two layers about 1-1.5 cm in depth.
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14. Approximate the perineal body at the attachment of the bulbospongiosus
muscles so as to restore the introitus and to bring the two labia together.
Care must be paid to the width of the introitus. (The crown stitch)
15. Repair of the perineum: Using the suture of the vagina or the crown stitch
or a new No.00 Vicryl the perineum can be closed subcutically or
continuously or interruptedly.
16. Per-vaginal and per-rectal examination is done to assure integrity of repair
and to exclude foreign bodies.
17. Documentation
18. Post operative instructions, including local care, antibiotics, analgesia and
laxatives
19. Follow-up

118
 GUIDELINES FOR MANAGEMENT OF MASSIVE OBSTETRIC
HAEMORRHAGE

1.Introduction:
It is the leading cause of maternal death world-wide; antepartum but mainly
postpartum. Proper review of the risk factors enables the doctor to anticipate it in
a large number of cases and hence the doctor MUST BE WELL PREPARED to
manage it. In few cases it is unanticipated, even though the doctor MUST BE
ABLE TO MANAGE IT.
These guidelines describe the initial management of massive obstetric
heamorrhage and problem related to massive blood transfusion. The specific
treatment of stopping the bleeding is described in the appropriate guidelines;
APH, PPH, Ruptured uterus and acute inversion of uterus.

2. Diagnosis:
Perceived blood loss of < 1000 ml (assessed visually) or any clinical evidence of
shock during pregnancy, labour, delivery or postpartum (usually in first 24 hours).

3. Management
SIMULTANEOUSLY; Resuscitate, monitor, investigate and stop the bleeding.
- Pallor, tachycardia, shock.

- Call for help. Inform consultant who MUST come immediately and lead
the treating team.
- Call anaesthetist
- Inform blood bank.
- Check airway and breathing. Maintain open airway
- Give oxygen 100% by face mask
- Fix 2 I.V canulae (14-16G) and take blood for CBC, clotting and
crossmatch 6 units of blood
- Head down tilt

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- Give warmed normal saline 0.9% as rapidly as needed while awaiting
blood.(up to 2 liters)
- Can give colloid e.g. Gelofusine, heamagel, haemaccel (maximum 1.5
liters)

- Once blood is available, give warmed blood as much and as rapidly as

needed.
o Crossmatched blood takes at least one hour
o Blood type specific takes 15 minutes
o O. negative blood immediately
- If no crossmatched blood available once 3.5 liters of crylalloids (normal
saline) and colloid (haemagel) are infused, give ORh Negative blood while
awaiting crossmatched blood.

- Use a warming device

- Use compression cuff to speed the transfusion
- Use warming blanket for the patient

- Intensive monitoring throughout

o Urine output via an indwelling catheter (hourly)
o Pulse, BP, Respiration and oxygen saturation (Pulse oximeter).
¼hourly
o If available use a monitor to record the vital signs and oxygen
saturation continuously
o If there is clinical evidence of coagulopathy (blood not clotted
visually) or if there is laboratory evidence of clotting disorder:
 Give warmed FRESH BLOOD
 Give one liter of fresh frozen plasma
 Give 10 units of cryoprecipitate
 Platelets are rarely needed
 Proper RECORD of all events
 Vital signs
 Fluids (amount)
 Blood and blood component (amount)
 Drugs and doses
 Interventions.
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4. Massive blood transfusion
Definition:Replacement by transfusion more than 50% of a patient's
blood in 12-24 hours.
Replacement of a patientُs total blood volume within a 24 hour period;
OR: Transfusion of 10 units of blood or more than 20 units of red cells
(packed cells) within 24 hours
OR: Replacement of more than 50% of blood volume within 3 hours.
- Blood transfusion strategy should be: to maintain blood volume and its
composition within limits that are safe with regard to haemostasis, blood
oxygen carrying capacity, oncotic pressure and plasma biochemistry.

- Investigations: Hb, PCV, platelets, prothrombin time(PT), Activated

Partial thromboplastin time (APTT).

- Replace by: Crystalloid, colloid, ORhNegative blood, whole blood.

- Platelets: To maintain count ≥ 50.000/ml

- Fresh frozen plasma indicated when PT or PTT is < 1.5 times the control
- Platelets +FFP+ Criopriciptate are given when there is evidence of DIC
Cryoprecipitate indicated if fibrinogen is less than 100 mg/100ml.

Complications of massive blood transfusion

- Acidosis:
o Stored red cells generate acids but the acidosis is mainly due to
hypovolaemia and the body can neutralize it. Usually bicarbonate
is not required.

o Hyprekalaemia
In stored blood there is increase in extracellular potassium;
rarely of clinical significance. Better use blood less than 7
days old.
o Citrate toxicity: Rare in patients with normal liver. Hypocalcaemia
with acidosis and hypothermia can cause bradycardia and
arrhythmias. Give calcium gluconate 10 ml of 10% calcium over
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 10 minuets. For every 4 units of blood give one ampule of calcium
gluconate.

o Depletion of coagulation factors and platels

Give fresh blood, FFP, cryoprecipitate and platelets.

o Hypothermia:
Increases risk of DIC. Prevented by giving warm blood. Can cause
arrhythmias

o Circulatory overload and Pulmonary Oedema

 Observe Pulse BP and respiratory rate and oxygen
saturation
 Auscultate the lungs for crepitations
 Give furosemide (lasix).

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 GUIDELINES FOR THE MANAGEMENT OF POSTPARTUM
COLLAPSE

Introduction:
Collapse can be due to a variety of causes, including innocent vasovagal faint
through to cardiac arrest, but the initial assessment and management is similar and
requires a systemic ABC approach (airway, breathing, circulation). The most
important cause is HAEMORRHGE which should always be considered FIRST.
In the majority of cases a cause can be identified if the approach is systematic; in
very rare situation a definite cause might not be found.
These guidelines list all the possible causes, their features and initial management.

1. Haemorrhage:
- Usually revealed; some concealed ( a rising uterine fundus
indicates increasing clot in the uterus due to uterine atonia, internal
haemorrhage, broad ligament haematoma
- Tachycardia, pale, cold, hypotension
- Saline+ blood+ treat cause.

2. Eclampsia:
- Associated with cerebrovascular accident, pulmonary oedema or
magnesium sulphate toxicity
- Hypertension, proteinuria, convulsions anti-dote Mg sulphate:
calcium gluconate; control hypertension.

3. Aspiration Mendelson’s syndrome

- complication of general anaesthesia especially when the patient is
not fasting. Inhalation after vomiting-gastric acidic contents
- shortness of breath, restless, cyanosis
- Bronchospasm
- Oxygen, aminophylline, steroids, diuretics, antibiotics

4. Anaphylaxis
- Drugs especially antibiotics
- Anaesthetic agents (general, regional, local)

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 - Rash, stridor, oedema
- Adrenaline (1 ml of 1 in 1000), hydrocortisone200mg I.V,
chorpheniramine 20 mg I.V.

5. Neurogenic; vasovagal, uterine inversion

- Vaginal examination if uterus is not outside
- Saline +blood +correct

6. Cardiogenic-heart disease
- Restless, chest pain
- Sit-up oxygen, forusemide
7. Bacteraemic shock:
- Sepsis due Garm negative rods or strept pyogens
i. Hypotensive, warm, fever
ii. Fluids +antibiotics

8. Amniotic fluid embolism

- Tetanic contractions, syntocinon hyperstimulation, scarred uterus,
polyhydramios, multiparity
- Restless, dysponoea, cynosis vaginal bleeding follows within 30
minutes due to DIC.
- Oxygen hydrocortisone, aminophylline, diuretics, adrenaline

9. Pulmonary embolism
- complication of DVT usually
- Restless, cyanosis, raised JVP
- Lie down + Oxygen+ I.V fluids +Heparin

10. Adrenal in sufficiency

- Inadequate or absent steroid cover in some one previously on
steroids pregnant women on steroids should be give hydrocortisone
200mg I.V during labour or caesarean section (stress)
- Hypotension
- I.V fluids +hydrocortisone; check Na and glucose.

11. Diabetic ketoacidosis

- Hyperventilaion +ketosis, Blood sugar
- I.V saline+ insulin
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12. Hypoglycaemia
- Diabetes, malaria, blood sugar
- Sweating, coma, convulsions
- I.V Glucose

13. Pneumothorax
- Chest pain +X-ray
- Aspirate, drain.

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 GUIDELINES FOR BLOOD TRANSFUSION

1. Introduction:
Blood is a tissue, transfusion from a donor to a recipient is a form of
alloqeneic transplant and inevitably carries some risk, including adverse
immunological interactions between the host and graft and transmission of
infectious agents. There are many compelling clinical indications for blood
transfusion in Obstetrics. Safe blood transfusion includes: proper grouping
and crossmatching, conforming to strict bedside procedures, early
diagnosis of complications and prompt treatment.

2. Clinically important blood groups systems:

- ABO, Rh, Others (Kell, Duffy, Kid)
- The red cell membrane contains cell surface molecules-antigens: A
antigen, B antigen, O antigen and Rh D antigen.
- The ABO and Rh D antigens are the most important in routine
transfusion and ante-natal practice
- ABO antigens:
Are oligosaccharide chains that project from the cell
membrane- the chains are attached to proteins and lipids that lie in
the cell membrane.
- They are inherited as Mendelian dominant
- They are coded by 3 allelic genes The A and B genes control the
synthesis of enzymes responsible for addition of a single
carbohydrate residue to a basic antigenic glycoprotein with a
terminal sugar L-fucose on the red cell, known as the H substance,
the O gene is an amorph and does not transform the H substance.

- Naturally occurring antibodies

i. Occur in the plasma of subjects who lack the antigen and
who have not been transfused or been pregnant. Most
important are anti-A and anti-B they are 1gM.

- Rh antigens: (15% are Rh Negative).

 Coded by allelic genes at 3 loci Cc Dd Ee

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  Eg: CDe from mother cde from Father genotype:
CDe/cde=RhD positive.
 RhD:Most important.
 Rh antibodies are immune antibodies- develop in response
to transfusion or transplacental. They are 1gG which can
cross the placenta.
 The most important immune antibody is the RhD antibody.
(Anli C, c. E, e are occasionally seen. There is no d
antibody).

- Blood grouping, ABO system

- Red cells suspended in saline agglutinate in the presence of:
anti A=group A
anti B= group B
anti A+ anti B=group AB
no agglutination=group O
- Blood to be tested on 2 slides. Add anti A to one slide and anti-B to
the other. Agglutination in anti-A=group A, in anti-B=group B, in
both=group AB. No agglutination=Group O.
- Blood to be tested+ Anti sera I gG+IgM
Agglutination means Rhesus Positive
No agglutination means Rhesus Negative.
- Crossmatching:
- Donor's cells +recipient serum
- Must be compatible ABO and Rh systems
- Mix and incubate
- Agglutination detected visually or microscopically=not
compatible
- Usually takes 45 minutes.
- Transfusion of uncrossmatched blood should be avoided
- In very urgent cases give ORh negative blood.
ABO blood groups antigens and antibodies
BLOOD RED CELL A OR B ANTIBODIES IN PLASMA FREQUENCY
GROUP ANTIGEN
O Non Anti A+ anti-B 46
A A anti-B 42
B B Anti A 9
AB A+B Non 3
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 - Rh antibodies:
- Direct Coombs test
i. Used for detecting antibodies on the cell surface where
sensitization has occurred in vivo e.g haemolytic disease of
the newborn
ii. washed RBCs + Antiglobulin
agglutination means positive
antibodies.
- Indirect Coombs test
- Used for detecting antibodies that have coated red cells in
vitro
- Step I :Red cells +serum of patient tested incubate and then
wash.
- Step II : Add antiglobulin Agglutination means positive.

Donation of blood:
- Test donor for grouping ABO and Rh, HIV,HBV, HCV, Syphylis.
- Under aseptic techniques, take 450 ml whole blood into a plastic
bag which contains 63ml anticoagulant (citrate phosphate dextrose
CPD)+ preservative (adenine).

- Blood Products:
Blood components are prepared from blood collected from donors.
They include; whole blood, platelets, fresh frozen plasma,
cryoprecipitate
- Whole Blood:
- Blood+ glucose +citrate+ adenine. ABO compatibility with
recipient is essential
- Store at 4ºc – 35 days
- Replace acute blood loss +severe anaemia
- Platelets:
- One adult dose is made from 4-5 donations of whole
blood.ABO compatibility is preferable
- Maintain platelets count < 50,000
- Each adult dose has approximately 2.5-3× 10 "platelets
128
 - Store at 22ºC:5 days only
- Fresh Frozen Plasma
- 150-300ml plasma from one donation of whole blood
- Replacement of coagulation factors deficiency e. g DIC

- Initial dose 15 ml /kg. further doses if bleeding continues and

guided by PT and APTT.

- Store at -30 ºc: 12months

- Packed red cells
- Chronic anaemia and anaemia during pregnancy
- Slow-transfusion +lasix.
- Cryoprecipitate:
- Fibrinogen from plasma 10-20 ml pack contains fibrinogen
150-300mg, factor 80-120 U
- Indicated if fibrinogen is > 100mg/dl.

Safe Transfusion Procedures:

- Errors leading to patient receiving the wrong blood are important
avoidable causes of mortality and morbidity.
- Most incompatible transfusions results from failure to adhere to
standard procedures for taking correctly labeled blood samples
from the patient and ensuring that the bag of blood is transfused.
- Each hospital should have a written transfusion policy that is used
by all staff who order, check, or administer blood.

1. Taking blood for per-transfusion testing ABO, Rh, Crossmatching

- Identify the patient from file and verbally
- Take the blood samples.
- Label the sample tube and complete the request from clearly and
accurately
- Do not write forms and labels in advance.

2. Administering blood:
- Identify patient from file and verbally
- Ensure that the identification of each blood bag, matches the
patientُs identification
- Check that the ABO and RhD groups of each bag are
129
 compatible with the patientُs
- Check each bag for evidence of damage and if in doubt do not use
and return to blood bank.
- The followings should be available with the patient before starting
transfusion: Hydrocortisone, antistine, adrenalin
-
3. Record Keeping
- Record in the patientُs notes; the reason for transfusion, the
product given, dose, any adverse effects and the clinical response.

4. Observation
- Transfusion should only be given when the patient can be
observed.
- Elective transfusion should be given at 8-10 a.m.
- BP, Pulse, Temp should be monitored before and 15 minutes after
starting each bag.
- In conscious patients, further observations are only needed if the
patient has symptoms or signs of a reaction
- Stay beside the patient for 30 minutes and should be available until
transfusions is finished.
- In unconscious patient monitor closely throughout transfusion.

Complications of blood transfusion

Early:
- Hemolytic reactions ABO incompatible red cell transfusion
- Reactions due to infected blood.
- Allergic reactions due white cells, platelets and proteins
- Pyrogenic reactions due to HLA antibodies
- Circulatory overload
- Air embolism
- Thrombophlebitis
- Citrate toxicity
- Hyper kalaemia
- Clotting abnormality after massive transfusion

Late:
- Transmission of disease
 HIV, HBV, HCV
130
  CMV
 Treponema pallidum
 Malaria

ABO incompatible red cells transfusion

- If red cells of incompatible ABO group are transfused (especially
group O recepient transfused with group A or group B or AB) the
recipient IgM ant-A, anti-B-or anti –A +anti –B binds to the
transfused red blood cells. This activates the full complement
pathway leading to intravascular haemolysis. The anaphylatoxins
C3a and C5a released by complement activation, liberates
cytokines and stimulate degranulation of mast cells with release of
vasoactive mediators. All these substances lead to inflamation,
increased vascular permeability and hypotension which in turn
cause shock and acute renal failure.
Another example:
- Group A(recipient)+ Group B transfused
- Ant-B(recipient)+ Antigen B on transfused red blood cells
Leading to haemolysis of transfused blood.
- Anti –A in transfused blood is small in quantity and does not cause
significant haemolysis of recipient red cells.

Symptoms or signs that arise during transfusion must taken seriously, as they
may be the first warning of a server reaction.

Investigation and management of reactions to blood transfusion.

Symptoms/signs of acute transfusion reaction

Fever, chills, tachycardia, hyper or hypotension, collapse rigors, flushing, urticaria, bone,
muscle, chest and/or abdominal pain, shortness of breath, nausea, vomiting generally feeling
unwell, respiratory distress

STOP THE TRANSFUSION

-Then manage
Measure accordingly
temperature, pulse, blood pressure, respiratory rate, Oxygen saturation
- Check the identity of recipient details on the unit.

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Then manage accordingly:
1.fever:
Febrile non – haemolytic transfusion reaction
- if temperature rises ≤ 1.5 ºc, observations are stable and patient is
otherwise well:
- Give paracetamol
- Restart transfusion at a slower rate and observe more
frequently.
2. Urticaria
Mild allergic reaction
- Give chlorphenamide 10 mg slowly IV
- Re-start the transfusion at a slower rate and observe more
frequently.

3. ABO incompatibility:
- Wrong blood bag infused
- Haemoglobinuria
- Most reactions are due to clerical errors
- Immediate is life threatening; massive intravascular haemolysis
- due to complement activating antibodies
- May occur only after few mls or up to 1-2 hours after end of
transfusion

- Urticaria, pain in the lumbar region, flushing, headache, chest pain,

shortness of breath, vomiting, rigors, pyrexia, hypotension, jaundice,
haemoglobinuria, DIC, acute renal failure.
- Investigations: haemoglobinuria
- Treatment: Main objective is to maintain BP and renal function.
- Take down the bag ang giving set and return intact to blood bank.
- IV saline infusion
- Indwelling catheter and measure urine output to be maintained at <
100ml/hour
- Give frusemide
- Treat DIC with fresh Frozen plasma or fresh blood
- Hydrocortisone 100mg iv
- Antibiotics
- Adrenaline
132
 - Further compatible blood may required
- Acute renal failure is treated by dialysis

In the Blood Bank

- Send unit and giving set to blood Bank
- Send post transfusion samples of the patient’s blood.
- Repeat the grouping in the pre and post transfusion samples and in the donor
blood and repeat the crossmatching
- Perform a direct antiglobulin test on the post transfusion sample
- Test plasma for haemoglobinaemia
- Test for DIC (platelets, fibrinogen, fibrin degradation products, PT, APTT.

4.Severe allergic reaction

- Bronchospasm, angioedema, abdominal pain, hypotension
- Stop transfusion and send unit and giving set and return intact to
Blood Bank
- Give chlorphenamine 10 mg slowly I.V
- Give Oxygen facial
- Give salbutamol nebulizer
- If severe hypotension or bronchospasm give adrenaline 0.5
mg im

5. Bacterial contamination
- Blood bag discoloured or damaged
- Rapid onset of hyper or hypotension, rigors or collapse .
- Take down unit and giving set and send to Blood Bank
- Repeat blood group, crossmatching, CBC, coagulation screen,
Blood urea and electrolytes
- Blood culture
- Urine output
- Broad spectrum antibiotics
- Oxygen+ I.V saline infusion

6. Acute dyspnoea/hypotenstion: Pulmonary oedema

- Monitor blood gases
- X-ray chest
- fluid over load
Give oxygen and furosemide 40-80 mg I.V.
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 GUIDELINES FOR FLUIDS AND ELECTROLYTES THERAPY

1.Introduction:-
In the majority of uncomplicated operative deliveries, the patients are kept fasting
for at most 24 hours and require replacement of the normal requirements of fluids
and electrolytes. Few patients develop complications (peritonitis, paralytic illus,
intestinal obstruction) which result in significant disturbances in water and
electrolytes. Such patients need careful assessment- clinical and biochemical- and
they need proper fluid and electrolytes therapy.

2.Normal distribution of body water and electrolytes:

- Water=60% of body weight
- Intracellular=25 litres. Main cation is Potassium K+
Main anions HPO-4 + Proteins
- Extracellular = 15 liters (12 liters intracellular, 3 liters plasma)
Main cation is Sodium Na+
Main anions Cl- + HCO3+ .

- Urea and electrolytes in venous blood (normal values).

ANALYSIS SI UNITS NON –SI UNITS
Sodium 135-145 mmol/L 135-145 meq /L
Potassium 3.3-4.7 mmol /L 3.3-4.7 meq/L
Urea 2.5-6.6 mmol /L 15-40 mg/dL
Creatinine 60-120 mmol/L 0.68-1.36 mg/dL

134
3.Fluid balance:
- Intake- 24 hours
3 litres, exogenous water –water+ food.
500 ml, endogenous water-oxidation of food

- Output-24 hours
i. Urine=1500 ml
ii. Feces=150 ml
iii. Lungs=400ml
iv. Skin invisible perspiration=1000ml

4.Sodium balance
- Principal cation of extracellular fluid
- Under strict control-Aldosterone conserve Na+
- Basic daily requirements= 100-140 mmol/day
- Following surgery there is reduced excretion of Na+ for 48 hours.

- Sodium depletion:
- Intestinal obstruction, rapid loss of gastric pancreatic and
biliary secretions
- High intestinal fistula
- Diarrhoea
- Vomiting
- The clinical features are dehydration (thirst, weakness, tachycardia,
hypotension, dry mouth, reduced skin turgor, confusion, stupor.

- The treatment is normal saline infusion

- Treat the undelying cause.

135
 - Sodium and water exess:
i. Heart failure, chronic liver disease, Nephrotic syndrome.
ii. Usually due to excessive infusion with saline (buffy face
and oedema).
iii. Treatment is by duiretics nad treatment of underlying
causes.

5.Potassium balance :
- Almost entirely intracellular (98%).
- Daily requirements= 70-100 mmol/day.

- K+ depletion
- Vometing, diarrhoea, intestinal obstruction, fistula,
nasogastric aspiration.
- Following surgery there is increased secretion of K+ due to
tissue destruction. Yet hypokalaemia is only considered
after 48 hours of surgery due to the good body reserve of
K+
- Most patients are asymptomatic
- Hypotonia, weakness, abdominal distension due to paralytic
ilius ECG= flattened T wave, ST depression.

- Treatment:
i. Oral potassium chloride (Slow-K) 2g 6
hourly
ii. Intravenous potassium
10 mmol in 500 ml saline 4 hourly
6 pints = 60 mmol in 24 hours.
iii. Treat the underlying cause.

Rules of potassium therapy:

- Urine output 40ml/hour or more
- Not faster than 40 mmol/hour
- Never in bolus dose.

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6.Parentral Fluid Therapy:
6.1 Solutions commonly in use
- Dextrose 5%: 50g/l (25g/500 ml)
Isotonic solution supplying water and calories without
electrolytes. Useful in postoperative period when there is reduced
Na excretion. Prolonged administration cause hyponatraemia.

- Isotonic 0.9% sodium chloride NaCL – Isotonic saline (-154

mmol Na +154 mmol Cl) per Liter
- Used to replace normal sodium requirements (500 ml-1000ml
of isotonic saline per day) and additional volume is required
when a large amount of Na has been lost by vomiting,
aspiration or fistula. May need 1000 ml of saline as daily
requirement in hot climates, sweating.

- Dextrose 4.3% with saline 0.18% (one fifth isotonic

solution) it is an isotonic solution and referred to as dextrose
saline

- Ringer's lactate:
Contains sodium (130), Polassium (4), chloride (110), lactate
(28), in all the same concentrations as plasma. It is used in
hypovolaemic shock awaiting blood.

6.2. Post operative fluid therapy

- Effects of surgery: Retention of Na+ and K+
- Antidiuretic hormone (ADH) is released in response to
surgery – conserving water
- Hypovolaemia causes aldosterone secretion and hence retention
of Na by the kidney
- Potassium is released by damaged tissues and blood transfusion
and hence potassium supplementation is indicated only after 48
hours.

137
Prescribing fluids after surgery
- Majority of patients require fluid replacement for a
short time-24 hours or less
- Some require resuscitation pre-operatively
(APH, dystocia, ectopic, ruptured uterus).
Patients operated on by the end of the list should have I.V
fluids pre-operatively.
- Some require replacement after surgery nasogastric
aspiration-cases in which the bowel is injured,
- Some require long term nutritional support e.g high intestinal
fistula.

Replacement of normal losses following uncomplicated operations e.g

Caesarean section, hysterectomy

- 3 litres (6 pints of 500ml)per 24 hours

o 5% Dextrose:2000ml, 2 litres, 4 pints+500ml-1000ml
Normal saline (COMMONEST IN USE)

o 5% Dextrose:2000ml +500ml Hartmann's solution.

o 4.3% Dextrose in 1/5th normal saline 3000ml

Replacement of abnormal fluid losses:

o Vometing, diarrhoea, nasogastric aspiration, high
intestinal fistula, these lead to loss of fluid rich in
electrolytes K+ +Na+
It also lead to acid base disturbance, vomiting is acidic
alkalosis
o Large occult losses occur in paralytic ileus and
intestinal obstruction. several litres may be sequestrated
in the gut contributing to hypovolaemia.
o Insensible losses in hot weather
o Hyperventilation due to pain and respiratory infection.
o Measure losses carefully: Vometing, aspiration, fistula,
diarrhoea, urine, for 24 hours
o Next 24 hours:
Give the normal daily requirement (3litres-2 liters 5%
138
 Dextrose+ One litre normal saline) + abnormal losses.
o Replace losses by equal volumes of normal saline.
o Keep very accurate fluid-input and output charts
o Potassium:
Only after 48 hours and evidence of hypokalaemia by
serum electrolytes.
 Total=60mmol in 24 hours
 10 mmol in 500ml saline -5%Dextrose every 4
hours (6pints in 24hours)
- Measure serum electrolytes several times

Replacement of abnormal fluid losses: Admitted as emergency

- Fluid losses of under 5% body water are difficult to detect
clinically.
- Fluid Losses of more than 15% of body water cause marked
circulatory collapse
- Losses between 5-15% body water can be detected clinically
(dry mouth, sunken eyes, tachycardia, hypotension reduced
urine output).
- Estimate clinically
- Calculate deficit 42 litres × 10=4.2 litres
100
- Give ½ the amount quickly and the rest slowly-Normal saline.
- The best guide is urine output.

139
GUIDELINES FOR THE MANAGEMENTMANAGEMENT OF ECTOPIC
PREGNANCY

1. Introduction:
A serious condition which can cause maternal death or infertility. Its
incidence is increasing. Early diagnosis is important to prevent mortality
and morbidity and hence a doctor must have a high index of suspision
when a patient presents with short period of amenorrhoea, vaginal
bleeding and pain.
The fertilized ovum implants outside the uterus-usually the tube (70% in
the ampulla) and then pregnancy fails leading to sloughing of decidua and
vaginal bleeding. The fate of such pregnancy is: erosion of the tube-
rupture-and internal haemorrhage, tubal abortion, chronic haematoma and
sometimes spontaneous regression.
The main risk factors are: pelvic inflamatory disease, previous pelvic
surgery, IUCD, previous ectopic pregnancy and a history of infertility

2. Management of haemodynamically stable patient suspected ectopic

2.1. Diagnosis:
2.1.1 Clinical
- Short period of amenorrhoea
- Pain: Universal, Unilateral or bilateral lower abdominal
pain due to tubal abortion or erosion
- Vaginal bleeding: Usually mild but could be
quite heavy. Passage of decidua may be
confused with abortion
- Tenderness: lower abdomen or whole abdomen. Tender
vaginal examination. Tender adenexal mass (usually no
mass is felt)
Excitation test positive, not specific.

Note: Vaginal examination should be done in all suspected

cases, however it may not give useful information and
sometimes may even be harmful
- rupture of intact ectopic.
140
2.1.2. Biochemical measurements
- Pregnancy test = positive
- Serum BhCG = 1000 IU/L

2.1.3. Ultra-sound
- Trans abdominal: Intra-uterine pregnancy
rules out ectopic
- Transvaginal: Intra-uterine pregnancy rules out ectopic
- Transvaginal Empty uterus +one or more of the followings is
diagnostic for Ectopic.
 Adenexal gestational sac+an embryo (viable or
non viable)
 Adenexal gestational sac+ yolk sac
 Echogenic adenexal mass +fluid.
2.2 Treatment:
- Admit +assess +diagnose (clinical, U/S, hCG)
- If there is enough evidence of diagnosis (pregnancy test +ve,
βhCG, U/S as described above) prepare 4 units of blood and
proceed for laparotomy as soon as possible.
- Observation:
- Pain, vaginal bleeding, pulse, blood pressure, abdomen.
- CBC, grouping and crossmatching and prepare 4 pints of blood.
- If there is deterioration in signs, proceed for laparotomy.

- Surgery:
Laparotomy for diagnosis and treatment salpingectomy. Ovary
should not be removed unless technically difficult to spare

- Expectant management: Limited use

o Minimal symptoms and signs
o Certain U/S diagnosis of ectopic (transvaginal empty
uterus +positive pregnancy test+ adenexal sac-may be
absent)
o No evidence of a vailable embryo
o Size > 5 cm
o No evidence of haemoperiotoneum on u/s
o Low serum BhCG > 1500 IU/l
141
 o Very strict follow-up. Do laparotomy if any
deterioration of clinical signs and/or u/s and /or serum
BhCG.
3. Management of Ruptured ectopic Haemodynamically unstable

3.1. Diagnosis
3.1.1. Clinical
- Short period of amenorrhoa, severe pain, shoulder pain, nausea,
vomiting, syncopy.

- Evidence of internal haemorrhage Distended tender abdomen-

silent

- Tachycardia, hypotension, pallor, shock

3.1.2 Biochemical
- positive pregnancy test
- serum BhCG > 1000 IU/l

3.1.3 Ultrasound
- Empty uterus +free intraperitoneal fluid with clots.

3.2 TREATMENT: (CALL FOR HELP):

- Two large I.V canulae
- Prepare at least 6 pints of blood
- Start I.V normal saline and soon blood transfusion
- Laparotomy when the systolic blood pressure reaches
100 mm Hg + salpingectomy
- Interstitial ectopic : corneal resection, rarely
hysterectomy
- Cervical and caesarean scar ectopics
Cervical: implantation of conceptus within the cervix
below the internal os.
- Caesarean scar ectopic: implanted into a deficient uterine
scar
- In both attempt to remove is associated with severe
haemorrhage and there may be a need for hysterectomy.

142
 GUIDELINES FOR THE MANAGEMENT OF GESTATIONAL
TROPHOBLASTIC DISEASE

1. Introduction :
The incidence varies geographically being higher in Africa and Asia.
Incidence in Wad Medani Teaching Hospital (1995-1997) was 4.46/1000
deliveries; hydatidiform mole=4.03/1000 and choriocarcinoma 0.44/1000.

WHO classification:
Pre –malignant: Partial and complete hydatidiform mole
Malignant: choriocarcinoma, invasive mole, placental site
tumour.
The cure rate approaches 95%, the majority of premalignant disease
require no further treatment after evacuation. The risk factors are:
extremes of age particularly 40+, high parity and a previous history of the
disease.

2. Clinical featuers and diagnosis

- exaggerated symptoms of early pregnancy, vaginal bleeding
(threatened abortion), funuds larger than dates and a doughy
abdomen, the passage of vesicles.
- U/S: snow storm appearance + Bilateral cystic ovaries.
- Serum Beta Human chorionic gonadotrophin (βhCG)=HIGH
- Symptoms and signs of metastasis; vagina, lungs, brain and liver.
- Histopathology
Mole: Oedematous avascular villi
Choriocarcinoma: Anaplastic cells invading muscle and
blood vessels, necrosis and haemorrhages.

3. Management :
3.1. Diagnosis: Clinical, U/S, βhCG
3.2. Investigations:
CBC, coagulation profile, X-ray chest and brain, CT
for liver and brain, ECG.
3.3. Prepare 4-6 pints of blood

143
3.4. Spontaneous expulsion
- May be associated with severe haemorrhage; transfuse liberally
with blood and saline.
- Then do urgent evacuation using ovum forceps (no sharp curette)
to stop the bleeding
- BEWARE OF PERFORATION OF UTERUS
- Give prophylactic antibiotics- third generation cephalosporin.
- Repeat evacuation 3-7 days later if there is indication (bleeding,
U/S evidence of remaininig molar tisuues) .
- Send products for histopathology.

3.5. Evacuation
- Suction evacuation whatever the gestational age or uterine
size
- Prepare and give blood 4 pints of blood least
- Insert 800 microgram of prostaglandin F2α analoque –
Misoprostol,
- OR Prostaglandin E2 vaginal pessaries in the posterior
vaginal fornix 6 hours before the suction evacuation.
- Evacuate under general anaesthesia using suction
evacuation under syntocinon (40 IU syntocinon in 500 ml
normal saline)
- Send all products for histopathology

3.6. After evacuation

- Next day: Quantitative serum βhCG
- Discharge patient 3-7 days after evacuation.
- First appointment for follow-up 2 weeks after
discharge.

3.7. Follow-up: clinical plus βhCG

- Every two weeks for 8 weeks and then monthly for
one year.
- In each visit:
- History of bleeding or evidence of metastesis
- General and vaginal examination
144
 - Investigation: βhCG, CBC, U/S

3.8.Vaginal bleeding post evacuation or evidence of

retained products by U/S
- admit to hospital
- BHCG + U/S
- Re-evacuation and send products to histopathology.

3.9. Contraception
Use contraceptive pills when the βhCG is normal.

3.10. Indications for chemotherapy

- Raised βhCG level 6 months after evacuation (even
if falling)
- βhCG plateau in three consecutive serum samples
- βhCG < 20,000 IU/L more than 4 weeks after evacuation
- Rising βhCG in two consecutive serum sample
- Pulmonary, vulvar or vaginal mets
- Heavy or continous vaginal bleeding or intraperitoned bleeding.
- Histological evidence of choriocarinona
- Mets in brain, liver, lung, GIT< 2 cm in X-ray.

3.11.Hysterectomy for patients ≥ 40 years and

grandmultipara.
3.12.Hysterectomy for choriocarinoma with severe
bleeding.
3.13.Postpone pregnancy for 2 years after chemotherapy
for fear of teratogenesis.

145
 GUIDELINES OF FOR THE MANAGEMENT OF
PRE-ECLAMPSIA AND ECLAMPSIA

1. Introduction:
Pre- eclampsia is a multiorgan disease process characterized by hypertension and
proteinuria. It is one of the leading causes of maternal mortality in the Sudan. It
has been estimated by WHO that worldwide approximately 60,000 women will
die each year from pre-eclampsia . The major complications are: eclampsia,
cerebal haemorrhage and pulmonary oedema-Attempts of prediction and
prevention of pre-eclampsia have not been successful, however early diagnosis
and appropriate management significantly reduce the incidence of serious
complications. As delivery is the only definitive cure of pre-eclampsia, it is one of
the common causes of iatrogenic pre-maturity.
These guidelines describe the methods of diagnosis and management of Pre-
eclampsia and eclampsia.

Pre-eclampsia:
1. Definitions:
1.1. Hypertension in pregnancy
A. Diastolic blood pressure ≥ 110 mm Hg on any one occasion
OR
B. Diastolic blood pressure ≥ 90 mm Hg on two or more
consecutive occasions 4 – 6 hours apart.

1.2. Proteinuria in pregnacy:

A. One 24 hours collection with total protein excretion ≥ 300 mg
per 24 hours OR
B. Two clean catch mid-stream urine ≥ ++ (1 gm albumin/L).

1.3. Pregnancy induced hypertension (PIH):

- Hypertension developing after 20 weeks of pregnancy, during
labour or the puerperium in a previously normotensive woman.
1.4. Pregnancy induced proteinuria:

146
 - Proteinuria developing after 20 weeks of pregnancy, during labour
or the puerperium in a previously normotensive non-proteinuric
woman.

1.5. Pre-eclampsia:
- Is a syndrome defiend as pregnancy induced hypertension and
pregnancy induced proteinuria that may be associated with other
features such as oedema, symptoms and abnormal laboratory
findings.

1.6. Eclampsia:
- The presence of fits (grandmal seizures) in a pregnant woman with
pre-eclampsia and absence neurological abnormalities e.g.
epilepsy.

1.7. Pre-eclampsia supeimposed on chronic hypertension:

- New onset proteinuria in a woman with chronic hypertension.

2. Risk factors:
2.1. Primigravida.
2.2. Previous history of pre-eclampsia.
2.3. Pre-existing diabetes mellitus.
2.4. Multiple pregnancy.
2.5. Family history; mother or sister.
2.6. Body Mass Index (BMI) above 35 kg/ m2.
2.7. Age above 40.
2.8. Chronic hypertension and chronic renal disease.
2.9. Antiphospholipid syndrome.

3. Diagnosis of pre-eclampsia:
- A syndrome; a group of symptoms and signs.
- The essential criteria for diagnosis are PIH and proteinuria.
- Measure BP sitting or lying on one side.
- Use mercury sphygmomanometer – large cuff where appropriate
- Diastolic BP = Kortocoff 5 exept in those BP approaches zero.

Criteria of pre-eclampsia(diagnosed by PIH + Proteinuria)

- PIH.
- Pregnancy induced proteinuria.
- Generalized oedema.

147
 - Hyperuricaemia; indicates severity.
- Increased haematocrit; indicates decreased circulatory volume .
- Thrombocytopenia:
o > 100.000/ml.
o > 50.000/ml – bleeding.
- Elevated liver enzymes: ALT AST.
- Hypocalciuria.
- Intra uterine growth retardation (IUGR).

14- Criteria of severe pre-eclampsia:

- BP of ≥ 160 mm Hg systolic or ≥ 110 mm Hg diastolic on at least
two occasion 6 hour apart.
- Oliguria ≤ 400 ml in 24 hours.

- Symptoms:
o Visual disturbances (bluring of vision, diplopia, flashes
infront of the eyes), epigastric pain, headache, nausia,
vomiting.
o Could be asymptomatic (50%).
- Pulmonary oedema (reduced intravascular volume, leaking
capillaries and low serum albumin).
o HELLP syndrome:
o H – Haemolysis.
o EL – Elevated Liver enzymes ALT AST hepatocellular
damage.
o LP – Low platelets.
- Proteinuria ≥ 3 gm per 24 hours.
- DIC.
- Hyperuricaemia.
- IUGR.

4. Management:
4.1. Hospital admission:
- All cases – mild to severe - are treated in hospital for at least 4-7
days after delivery.
4.2. Intial maternal assessment:
o History; identify risk factors.
o Dating of pregnancy (LMP, early U/S),

148
 Starting early expect more maternal and fetal complications.
- Check BP repeatedly- 6 hourly

- Biochemical tests; haematological tests:

o CBC, 24 hours urine protein, blood urea, serum creatinine,
ALT, AST, serum bilirubin, uric acid, platelets count, PCV,
fibrinogen if DIC is suspected, clotting profile PT INR
(especially when spinal anesthesia is indicated).

4.3. Initial fetal assessment:

o Gestational age (LMP, examination, U/S).
o Biophysical profile (tone, liquor, activity, and breathing
movement)+CTG.

4.4. Monitoring:
4.4.1. Daily morning and evening and closer if needed:
o BP, symptoms, urine, fetal heart.
o Kick count.
o Fluid balance chart.
4.4.2. Weekly:
o Biophysical profile and heamtological tests.
o U/S.
o CTG (basal fetal heart rate, acceleration, deceleration,
variability).
5. Hypotensive drugs:
- All patients at all gestational ages.
- Methyldopa: 250 – 500 mg 8 hourly, maximum 3 – 4 gm per day.
- Nifidipine: 10 – 20 mg 8 hourly maximum 120 mg/day.
- Labetalol: 100 mg 8 hourly, maximum 1200 mg/day.

6. Terminate pregnancy:
6.1. Mild PE terminate at 38 weeks.
6.2. Severe PE terminate immediately.

6.1. Mild pre-eclampsia:

- BP > 160/100; no evidence of severe PE, mother and fetus not
at danger.
- Terminate at 38 weeks by induction of labour or caesarean
section.
149
 - Induction of labour:
 Use CTG.
 Give dexamethasone 48 hours before induction.
 Could use forceps or ventouse in second stage.
 Do not give ergmetrine in the third stage, give
syntocinon.
 If BP rises during labour give hydralazine or do
Caesarean section.

- Caesarean section:
 Give dexamethasone 48 hours before C/S.
 Spinal anaesthesia.
 Contracted pelvis, malpresentation, malposition,
multiple pregnancy, scarred uterus, relative
infertility, elderly primigravida.
 Do not give ergmetrine in the third stage, give
syntocinon.

- If delivery by induction or C/S observe patient closely for 4

days.
6.2 Severe pre-eclampsia:
- diagnosis according to criteria of severe PE especially BP,
symptoms, disturbed haematological and biochemical tests,
pulmonary oedema.
- Admitt to intensive care unit (ICU) and inform consultant
on duty.
- Assess the mother and the fetus clinically.
- Close observation (hourly – ¼ hourly) pulse, BP,
respiration, temperature, urine output and fetal heart.
- Intravenous access wit16 g canula.
- Indwelling catheter (amount of urine and proteinuria).
- Facial oxygen.
- Full investigations; haematological and biochemical.
- U/S and CTG.
- Hypotensive drugs:

150
  Hydralazine:
Intravenous hydralazine 5 mg bolus slowly
repeated every 15 minutes if required to a
maximum cumulative dose of 20 mg. Montor BP
every 15 minutes and stop hydralazine when
diastolic BP = 100 mm Hg.
OR: hydralazine infusion 40 mg in 40 ml saline 1-5
ml per hour (1 – 5 mg per hour). Monitor BP
regularly every 15 minutes and stop hydralazine
when diastolic BP = 100 mm Hg.
Hdralazine may cause fetal bradycardia sp prelude
the circulation with a crystalloid and monitor fetus
continously by CTG.
 Labetalol:
- Ensure no contraindications – exclude
bronchial asthma.
- 20 mg intravenous bolus dose followed by
40 mg if not effective within 10 minutes,
then 80 mg every 10 minutes to a maximum
dose of 200 mg. It mayy precipitate fetal
distress.

Anticonvulsant:
- Magnesium sulphate
- It halfs the incidence of eclampsia.
- Loading dose of Magnesium sulphate of 4 gm in 5% dextrose
intravenously given slowly over 10 minutes. Then followed by a
maintenancy infusion of 1 g per hour for at least 24 hours after delivery.
- Monitor toxcicity:
 Respiratory rate - hourly.
 Patellar reflex - hourly.
 Urine output - hourly.
- Stop (or reduce) Magnesium sulphate if:
o The patellar reflex is not present.
o Respiratory rate is > 12 per minute.
o Urine output is > 25 ml per hour.
- If loss of patellar reflex does not return within one hour of stopping or
reducing the Magnesium sulphate and there is respiratory depression > 12

151
 minute give calcium gluconate: 10 ml of 10% calcium gluconate (1 gm)
intravenous slowly over 10 minutes.
- When Magnesium sulphate is resumed it should be at a reduced dose.
- Intubate if the patient developed respiratory arrest.

Delivery:
- Give dexamethasone before delivery.
- Terminate pregnancy by caesarean section 4- 6 hours after severe
hypertension is controlled, irrespective of gestational age.

- Induction of labour: could considered if:

 Term or near term – favourable cervix and no contraindication for
vaginal delivery.

- Anaesthesia:
 Spinal anaesthsia or epidural anaesthsia.
 Preload circulation with 500 mL saline to reduce the risk of
hypotension.
 Endotrachial intubation can cause severe hypertension and hence
general anaesthesia is not recommended.

- Fluid therapy:
 Close monitoring of fluid input and urine output.
 1 ml/kg/hour dextrose 5%
1x60x24 = 1440 ml/24 hours.
 Duiretics should not be given unless there is pulmonary oedema.

- Continue the same close observation (hourly) and Magnesium sulphate

infusion for 24 (48) hours after delivery.
- Continue hypotensive drugs if blood pressure diastolic 110 or more.
- Anticipate complications (eclampsia, pulmonary oedeam, cerebral
haemorrahage, renal failure).
- Close monitoring of BP for 4 days.
- Repeat biochemical and haematolocical investigations.

152
 GUIDELIENES FOR THE MANAGEMENT ECLAMPSIA:

1.Definition:
 The presence of fits (grandmal seizures) in a pregnant woman with pre-
eclampsia and abscence of neurological abnormalities e.g. epilepsy.

 As a role thumb “it is prudent to consider any convulsion in a woman in

the third trimester or early peurperium (first 24 hours after delivery) as
eclampsia”.

 It is rare before 20 weeks in the abscence of trophoblastic disease.

 Could be:

 Antepartum = 71%.

 Intrapartum and postpartum = 29%.

 Fit:

 Premonitory phase: twitching, facial congestion, foaming of the mouth,

deepening of loss of consciousness.

 Tonic phase: deep muscular rigidity.

 Clonic phase: jerky movement all over.

 (all above events last for 1 – 1.5 minutes during which no respiration).

 Coma + breathing.

 Reovery: concious – confused – agitated.

2. Presentation:
 Brought with history of fits.

 Fits witnessed by doctor.

 Brought in coma.

153
 1. Management: CALL FOR HELP+ ICU+Inform consultant and
anaesthitist.

3.1- Management of fit:

 An eclamptic fit is self limited.

 Give Magnesium sulphate 4 g intravenously slowly.

 Do not attempt to shorten or abolish the initial fit by using drugs such as
diazepam or phenytoin. Can lead to respiratory depression, aspiration or
respiratory arrest; particularly when given with magnesium sulphate.

 Protect the airway and minimize the risk of aspiration by placing the
woman on her left side and suctioning the foam and secretions from her
mouth.

 Protect patient from falling down of bed.

 At the end put patient on the left lateral position to avoid inhalation of
vomiting and vomiting and secure airway.

 Suction of secretions.

 Facia oxygen.10 L /min.

3.2. Management in intensive care unit:

 Avoid bright light and loud noise.

3.3. Inform consultant on duty.

3.4.Treatment and prophylaxis of fits:

 Magnesium sulphate:

 Reduces cerebral ischaemia by acting as membrane stabilizer and

vasodilator and it is superior to both Diazepam and Phenytoin in
preventing further fits.

 Loading dose of Magnesium sulphate of 4 gm in 5% dextrose

intravenously given slowly over 10 minutes. Then followed by a
154
 maintenance infusion of 1 g per hour for at least 24 hours after last
convulsion.

 Give 25 mg Promethasin I.M with the loading dose to prevent vomiting.

 If the patient has a second convulsion after the loading dose – another
bolus of 2 g slow I.V could be given.

 A total dose of 8 g of Mg sulphate should not be exceeded over a short

period of time.

 Monitor toxcicity:

 Respiratory rate - hourly.

 Patellar reflex - hourly.

 Urine output - hourly.

 Stop (or reduce) Magnesium sulphate if:

 The patellar reflex is not present.

 Respiratory rate is > 12 per minute.

 Urine output is > 25 ml per hour.

 If loss of patellar reflex does not return within one hour of stopping or
reducing the Magnesium sulphate or there is respiratory depression > 12
minute give calcium gluconate: 10 ml of 10% calcium gluconate (1 gm)
intarvenous slowly over 10 minutes.

 When Magnesium sulphate is resumed it should be at a reduced dose.

 Intubate if the patient developed respiratory arrest.

Hypotensive drugs:
 It prevents cerebral haemorrhage.

 Given if systolic pressure < 160 mm Hg or diastolic pressure < 100 mm

Hg.

155
  Intravenous hydralazine 5 mg bolus slowly repeated every 15 minutes if
required to a maximum cumulative dose of 20 mg. Montor BP every 15
minutes and stop hydralazine when diastolic BP = 100 mm Hg.

 OR: hydralazine infusion 40 mg in 40 ml saline 1-5 ml per hour (1 – 5 mg

per hour). Monitor BP regularly every 15 minutes and stop hydralazine
when diastolic BP = 100 mm Hg.

 Hdralazine may cause fetal bradycardia, prelude the circulation with a

crystalloid and monitor fetus continously by CTG.

Nursing:
 ICU – avoid bright light and loud noises.

 Assess mother and fetus clinically

 Close observation (hourly – ¼ hourly)

 Convulsions

 level of conciousness

 pulse, BP, respiration, auscultation of the chest, temperature and fetal

heart.

 urine output.

 patellar reflex.

 Nurse in the left lateral position to prevent aspiration of secretion and

ensure patent airway.

 Intravenous access with 16G canula

 Indwelling catheter (amount of urine and proteinuria and prevent retention

of urine).

 Facial oxygen 10 L/min

 Manage fit if develops.

 Full investigations; haematological and biochemical.

156
  CBC, Urine for albumin, blood urea, serum creatinine, ALT, AST, LDH,
serum bilirubin, uric acid, platelets count, PCV, clotting profile (PT INR),
blood film for malaria, blood sugar.

 U/S and CTG.

Delivery:
 Give dexamethasone before delivery.

 Delivery should be attempted only after seizures are controlled, severe

hypertension controlled and hypoxia corrected – usually 4- 6 hours.

 Perform vaginal examination – usually after 4 – 6 hour. Sometimes you

need to perform vaginal examination earlier if there is clinical evidence of
imminent delivery.

 Terminate pregnancy irrespective of gestational age.

 Deliver by caesarean section if the patient is not in labour (rare) or in early

labour.

 If in advanced labour and no contraindications for vaginal delivery : ARM

+ syntocinon.

 Instrumental delivery under general anaesthesia in the second stage.

 If already in the second stage deliver by Ventose or Forceps under general

anaesthesia.

 Do not give Ergometrine in third stage of. Use syntocinon.

Anaesthesia: inform anaesthetist.

 General anaesthesia to avoid trigger new fits.

 Be ware that endotrachial intubation could cause severe hypertension.

 Spinal or epidural ???.

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Fluid therapy:
 The two most important factors that atribute to maternal death are severe
hypertension and fluid intake.

 Close monitoring of fluid intake and urine output.

 1 ml/kg/hour dextrose 5%

 1x60x24 = 1440 ml/24 hours.

 Duiretics should not be given unless there is pulmonary oedema.

 Continue the same close observation (hourly) and Magnesium sulphate

infusion for 24 (48) hours after last fit.

 Give Hydralazine if blood pressure diastolic is more 100.

 Be ware of complications (pulmonary oedema, cerebral haemorrahge).

 Give prophylactic Heparin starting 24 hours after delivery.

 Close monitoring of BP for 4 days.

 Repeat biochemical and haematolocical investigations.

 Give Dexamethason 10 mg I.V if there is thrombocytopenia and continue

till the platelets return to normal

Recurrent seizures after starting Magnesium sulphate:

 If repeated seizures occur after Magnesium sulphate, give 2 g Magnesium
sulphate bolus dose. Do not exceed 8 g in short period of time.

 If still seizure not controlled:

 Give Diazepam 10 mg I.V slowly bolus and repeat if convulsion recurred.

Then follow by 40 mg Diazepam in 500 ml dextrose and titerate to make
the patient well sedated but arousable.

 Continue for 24 (48) hours after last fit.

 If Diazepam fails use phenytoin.

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  If patient is fitting continuously and not responding to all anti-convulsant

 (rare) give Thiopentone:

 Administered by anaesthetist.

 50 mg I.V.

 Intubate and ventilate.

 Delivery by caesarean section.

 In rare cases Magnesium sulphate contraindicated.

 Neuromuscular disease.

 Myasthenia gravis.

 Renal failure.

 Cardiac disease.

 Use Diazepam and phenytoin(ECG monitoring .

Cardio-pulmonary arrest:
 Stop Magnesium sulphate and Hydralazine.

 Institute CPR.

 1 g Calcium gluconate slowly (10 minutes).

 Intubate immediately and manage with assisted ventilation.

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 GUIDELINE OF SCREENING FOR AND MANAGEMENT OF
GESTATIONAL DIABETES MELLITUS (GDM) - DIABETES MELLITUS
(DM) WITH PREGNANCY

Introduction
GDM is defined as any degree of glucose intolerance with onset or first
recognition during pregnancy.
Early clinical recognition of GDM is important because therapy, including
medical nutrition therapy (MNT), insulin when necessary, and antepartum fetal
surveillance can reduce prenatal morbidity and mortality.
Minor abnormalities of glucose metabolism without GDM are significant risk
factors for fetal over growth and these minor abnormalities cannot be detected
without screening. If risk factors alone determined whom to be screened, half of
all cases of GDM would have been missed, although there is less risk for
gestational diabetes in low risk women, low risk women with GDM are at equal
risk for complications.
It was found that over half of all patients who exhibit an abnormal Oral Glucose
Tolerance Test (OGTT) lack risk factors for GDM.
Known diabetic mothers are higher risk of miscarriage and fetal congenital
abnormalities and macrosomia. Preconceptual blood sugar control may reduce all
these complications.
General objective:
The aim of this guidelines is to identify the pregnant women at risk to develop
GDM by doing screening, diagnoses and blood sugar control to reduce maternal
and neonatal mortality and morbidity.

Screening for GDM:

 GDM has many risk factors according to it pregnant women are classified
into high and low risk

The high risk group include women with:

 Body mass index more than 26 kg/square meter

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  Past history of GDM

 History of baby more than 4 kg

 History of intrauterine fetal death in the third trimester

 Past history of GDM

 Family history of DM in the first degree relatives

 History of baby with congenital malformation

 Glycosuria

 Proteinuria and hypertension

 Recurrent abortions

The low risk group:

 Women at 25 years old or less

 Body mass index less than 26 kg/square meter

 A member of ethnic group of low prevalence of Diabetes Mellitus

 No history of poor obstetric outcome.

 No family history of DM or abnormal glucose tolerance.

Criteria for selection of the screened group:

 All pregnant women selected for screening should not be know diabetic
before pregnancy or diagnosed as cases of GDM.

Timing of screening:
 18-20 weeks for high risk cases

 24-28 weeks for: Pregnant women with negative results of screening

at 18-20 weeks and low risk women.

Screening by loading dose glucose test (LDG):

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  All pregnant ladies subjected to the screening for GDM are on regular
diet, not fasting at the time of screening.

 All are given 50 gms oral glucose.

 The glucose is given in the antenatal clinic.

 The time of receiving the glucose should be registered.

 The patient is instructed not to take any food or fluid after the glucose
for 1 hour.

 She is allowed only for small amount of water.

Interpretation of the Results of 50 gm LDG Test:

 A plasma glucose level 140 mg/dl (7.8 mmol/L) or less is regarded as
normal level.

 Any result of plasma glucose > 140 mg/dl (7.8 mmol/L) is considered
as abnormal.

 All patients with abnormal results are subjected to Oral Glucose

Tolerance Test (OGTT).

 OGTT:

 It is the main test performed during pregnancy to diagnose gestational

diabetes mellitus (GDM).

 It is two hours test using 75gm glucose (WHO)

 The pre-requisites for OGTT include:

Patient on regular diet for at least 3 days prior to the test, overnight fast
for 8-12 hours before the test and the test will start early in the
morning at 8 a.m.

Interpretation of two hours (75gm) OGTT

 GDM is diagnosed when at least one plasma glucose level exceeds the
following values:

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 - Fasting plasma glucos =126 mg /dl (7.0 mmol/l)
- Two hours after glucose =200 mg /dl (11.1 mmol/l)
 Intolerance or impaired oral glucose tolerance (IOGTT) is diagnosed when
the plasma glucose is less than 200 mg/dl and more than 140 mg/dl.

Management of Cases with Intolerance or Impaired OGTT

 They are managed as cases of GDM. Advised for low carbohydrate diet.
 Followed in the antenatal clinics every 2 weeks till 36 weeks then weekly.
 Fasting Blood Sugar (FBS) and 2 Hours Post Prandial (2 HPP) in each
visit.
 FBS 105 mg or less, 2 HPP < 140 mg is accepted as controlled plasma
glucose level.
 Any increase in blood sugar above these levels, admit patient to the
hospital for blood sugar control.
 Patients are planned for Spontaneous Vaginal Delivery (SVD) or induction
of labour at 38 weeks.
 Caesarean Section (C/S) elective at 38 weeks if other reasons necessitate
e.g. repeat C/S or placenta praevia.

Management of cases with GDM and diabetic mothers on diet or oral

hypoglycemic drugs:
 Admit mothers with GDM after diagnosis.
 Admit known diabetic mothers after diagnosis of pregnancy.
 Advised for diabetic diet (low carbohydrate diet)
 Random blood sugar six hourly for 24 hours and give units of soluble
insulin according to the sliding scale below:

Blood sugar level Therapeutic dose of insulin

108-144 mg/dl zero units
144-198 mg/dl 2 units
198-252 mg/dl 6 units
252-342 mg/dl 10 units
342-432 mg/dl 14 units
> 432 16units to inform the treating doctor

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 - After 24 hours calculate the total dose of insulin received by each patient.
- Give two third of the calculated insulin in the morning and one third in the
evening in the form of mixed insulin (12 hourly).
- Follow the patients in the wards by using the fasting blood glucose and two
hours Post Prandial (2HPP) .
- Add soluble insulin if the 2HPP exceeds 140 mg/dL after breakfast or dinner.
- Add mixed insulin if the fasting blood sugar exceeds 105 mg/dL or the two
hours PP after lunch exceeds 140 mg/dL.

 After the blood sugar is adjusted, the patients are trained how to take the dose
of insulin and how to inject themselves before discharged home.
 After discharged, they are followed up in the antenatal clinic and according to
the every 2 weeks till 32-33 weeks then weekly till term.
 Their blood sugar is tested following fasting blood sugar and two hours PP
three times per-day every two weeks.
 The fetus is evaluated by ultrasound monthly.
 Readmission of the patients at any time if the 2-HPP blood sugar exceeds 140
mg/dL or fasting blood sugar exceeds 105 mg/dL.
 Readmission at 36 weeks for blood sugar readjustment and plan of delivery.
 Fetal evaluation by CTG ,ultrasound for fetal well-being and estimated fetal
weight.
 Induction of labour if the cervix is favorable at 38 weeks.
 Caesarean section ( CS) at 38 weeks if the cervix is not favorable or there is
other indication for caesarean section like :
- Macrocosmic baby or previous CS scar.
 For all primigravadae with no associated complications e.g. PIH etc. do
clinical assessment of the pelvises, CS is planned for those with any degree
of contracted pelvises. Those with adequate pelvises are planned for
Induction of labour.

Management of diabetic pregnant women on insulin:

 Admit immediately after diagnosis of pregnancy
 Continue the same dose of insulin
 Test for blood sugar control by FBS and 2HPP 3 times /day.
 Test blood sugar for HB A1c level once monthly.

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  Adjustment of the blood sugar and continue management as mentioned
above.

Management of Diabetic Ketoacidosis (DKA):

Diagnosis of DKA
 Glycoseuria + acetonuria + symptoms and signs.
 Most in tyoe I diabetes due to missing of insulin.
 In type II look for a cause (infection, abscess)

Management:
 Normal saline 6 litres.
 Soluable insulin (10 IU I.V and 10 I.U I.M then 5 Units I.M hourly
till the disappearance of acetone.
 Treat underlying cause.
 Investigations.

DKA in labour:
 Same management, it is lethal to the fetus.
 If there is indication for caesarean section proceed for caesrean
section

Control of Blood Sugar and Monitor during Labour:

 Patients on Insulin who develop labour pain or induced; immediate
random blood sugar for assessment of their blood glucose.
 Apply the sliding scale and give soluble insulin according to the random
blood sugar hourly till delivery.
 Patients on diet their blood sugar is checked hourly and the patient
continued on low carbohydrate diet till delivery.
 Give soluble insulin at any time if blood sugar exceeds 140 mg/dL
according to the sliding scale regimen.
 Patient for elective CS; perform fasting blood glucose at 6 o'clock in the
morning before CS.

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  Apply the sliding scale to provide the need for Insulin during and after
delivery till the patient starts her ordinary diet in the post operative period
(P.O.)
 Women who do not require insulin during pregnancy are returned to their
regular diet after delivery.
 Patients required Insulin during pregnancy on the postoperative period are
given insulin according to the calculated dose.
 They are discharged on low carbohydrate diet.Their blood sugar is
evaluated after 2 weeks.
 Very few patients may remain with elevated blood sugar more than
180mg/dL and require insulin or oral hypoglycaemic tablets according to
the physician opinion up till 6 weeks after delivery and then referred to
the medical (diabetic) clinic.
 Mothers with controlled blood sugar (random blood 180 mg/dL or less) are
seen in the postnatal clinic after 6 weeks and advised for OGTT or fasting
blood sugar and 2 hours postprandial.
 Mothers who show abnormal results will be send to the medical (diabetic)
clinic.

Management of Neonates of Mothers with GDM:

 Start suction immediately after delivery of the head and complete after
delivery of the baby.
 Take cord blood sample from the placenta for blood group, Rhesus factor
and thyroid stimulating hormone, Random Blood Sugar (RBS), and
complete blood count.
 The babies are scored according to Apgar score at 1 and 5 minutes.
 The babies are covered and kept warm.
 If the RBS is normal (40 mg/100 ml) start breast feeding within two hours
after delivery.
 If the RBS shows mild hypoglycaemia (> 30 - <40 mg/dL) give
immediate intravenous glucose 10% and start immediate breast feeding
especially if the babies are term and their suckling is good.
 Cases with severe hypoglycaemia, blood sugar 30 mg/dL or less give
intravenous glucose infusion 10% at a rate of 2 ml/kg/min over 2-3
minutes. Then continuous in the form of dextrose 5% infusion at a rate of
6-8 ml/kg/min to keep the blood glucose level above 40 mg/100 ml or
more.

166
  Monitor the blood sugar every 30 minutes until it becomes stable.
 Start breast feeding after stabilization of the blood sugar and the babies are
able to suckle.
 If the babies are unable to suckle, the feeding continues through
nasogastric tubes.
 After stabilization of the blood sugar, monitor it every 2 hours till 8 hours
of age, then 6 hourly up to 24 hours.

Respiratory Distress Syndrome (R.D.S.):

 Hyaline membrane disease commonly occurs in babies of insulin
dependent diabetic mothers, especially preterm babies.
 Neonates who develop this complication, their treatment include:
lV fluid in the form of dextrose 5% infusion, endotracheal intubation and
mechanical ventilation, chest x-rays: shows white lungs that confirm the
diagnosis, give surfactant 100 mg/kg through the endotracheal tubes. The
doses are repeated according to the severity (maximum four doses) from 0-
4 hours, 12 and 24 hours of age if needed.

 Transient Tachypnoea of Newborn (TTN) is common in babies of diabetic

mothers on insulin or diet especially following CS. They are managed as
follows: admission to neonatal intensive care unit (NICU), administration
of O2 through masks, lV fluids in the form of dextrose 5% infusion,
suction, endotracheal intubation and mechanical ventilation if needed
(rare), frusemide (sometimes) and lV antibiotics. Cases will improve with
24-48 hours and discharge from NICU.

Serum Calcium
 Serum Calcium level is estimated at 6-12 and 24 hours of age for babies of
mothers with GDM on insulin. If low serum calcium (less than 6 mg/L) is
found, serum magnesium is measured. Symptomatic infants are treated
with calcium gluconate lV slowly 200 mg/kg body weight, then continue a
maintenance dose of 200 – 700 mg/kg/day by continuous infusion.
Hypocalcaemia usually settles in 3-4 days. Measure the serum calcium
every 12 hours during this period.

Neonatal Jaundice
 Serum bilirubin is tested in babies of diabetic mothers on insulin if they
showed evidence of clinical jaundice.

167
  Hyperbilirubinaemia is diagnosed when the serum bilirubin is 5–7 mg/dL.
Babies with hyperbilirubinaemia are treated with phototherapy in the 1st
week of life if the serum bilirubin is 15 mg/dL or less in full term babies,
and 12 mg/dL or less in preterm babies continue for 3-4 days till the serum
bilirubin returnes to normal. Exchange transfusion is done for jaundiced
babies if the serum bilirubin is 20-25 mg/dL in full term and below this
level in preterm but > 12 mg/dL. Give Phenobarbitone 5-8 mg/kg twice a
day for cases with neurological symptoms. Breast feeding is encouraged.

Polycythaemia
 Polycythaemia is diagnosed by haematocrit level which is elevated in
some neonates of mothers with GDM on insulin, and it is done at 4 and 24
hours of age. A level of 65% is normal. If the level of haematocrit is more
than 65% and the neonates are symptomatic e.g. tachypnoea,
hypoglycaemia or lethargy are managed by exchange transfusion.
 Give all neonates routinely BCG vaccines, vitamin K injections,
Erythromycin eye ointment and hepatitis B vaccines if the mothers are
hepatitis B positive.

168
GUIDELINES ON THE MANAGEMENT OF MALARIA IN PREGNANCY

Introduction:
- Malaria is the commonest medical problem with pregnancy in the Sudan
particularly in the Gezira State.
- It is one of the major causes of maternal mortality and perinatal mortality
(pre-maturity and IUGR)
- Pregnant women-particularly primigravidae are more at risk of malaria
infection and its complications due to reduced immunity.
- The causative agent is the parasite Plasmodium, mainly Plasmodium
falciparum (90%).
- The disease is fatal if not treated and hence prompt chemotherapy is
mandatory.
- These guidelines help doctors choose the effective drug which is safe for
mother and fetus.

Diagnosis of Malaria:
1. Uncomplicated malaria:
- Clinical: Fever: headache, vomiting, sweating etc.
- Laboratory: Confirm diagnosis by thick blood film Giemsa stain. Shows
asexual form of parasite (trophozoite) Gold standard
OR: Rapid diagnostic test (RDT), Immuno-Chromatographic test (ICT).
Used at emergency.

2. Severe falciparum malaria: Diagnose by thick blood film Giemsa stain

plus one or more of the following features: Cerebral malaria, acidotic
breathing, convulsions, circulatory collapse, pulmonary oedema, abnormal
bleeding, jaundice, haemoglobinurea, severe anaemia (Hb> 5g /dl),
hypoglycaemia (blood sugar >40 mg/dl), acidosis, hyperparasitaemia,
renal impairment.

Management of malaria in pregnancy:

This includes: Treatment of malaria, management of complications and
management of labour
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Treatment of malaria:
- Admit all patients with significant symptoms and positive blood film
- Assess the severity of the condition clinically palor, jaundice, blood
pressure, temperature, level of consciousness
- Assess by laboratory: complete blood count (CBC), urine analysis, parasite
count, serum bilirubin, serum creatinine, blood sugar, liver functions tests,
renal functions tests.
- Monitor maternal and fetal vital parameters 4 hourly
- Monitor fluid intake and output daily
- Choose the drug according to severity and gestational age (table)
- Avoid over dose and under dose, avoid fluid overload. Give the drug for
the recommended duration
- Start treatment immediately.

Drug treatment of uncomplicated malaria in pregnancy

First Trimester:
- Oral Quinine:
10mg/kg body weight 8 hourly for 7-10 days (2 tabs-600mg-8
hourly for 7-10 days)

Second and Third Trimester:

- Oral Quinine: 10mg/kg 8hourly for 7-10 days
- OR: Qral Quinine 10 mg/kg 8 hourly for 3 days followed by
Sulphadoxine- Pyrimethamine (Fansidar) 3 tabs.
- OR: A combination of Artesunate (AS) and Sulphadoxine-
Pyrimethamine (SP) as follows:
 FIRST DOSE:
o Give both (AS+SP) simultaneously, (4mg/kg body
weight AS)+ (25 mg/kg body weight Sulphadoxine
+ 1.25 mg/kg Pyrimethamine) (3 tabs Fansidar+2
tabs AS).
 SECOND DOSE: 24 hours after first dose
o Give AS only
o 4 mg/kg body weight (2 tabs AS)
 THIRD Dose :24 hours after second dose
o Give AS only
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 o 4 mg/kg body weight (2 tabs AS).

Forms of antimalarial drugs in Sudan

Quinine:
- Tablets: (300mg).
- Quinine hydrochloride or Quinine dihydrochloride or Quinine sulphate
- Ampules (600mg or 300mg ampuls) Quinine dihydrochloride)

Artesunate (AS)
- Tablets (100mg or 50mg)

Sulphadoxine- pyrimethamine (Fansidar) (SP)

- Tablets (500mg Sulphadoxine+25mg Pyrimethamine).

Dosage schedule for AS+SP tabs

DAY1 DAY 2 DAY3
SP AS AS AS
S500mg+P25mg 100mg 100mg 100mg
3 tabs 2tabs 2tabs 2tabs

Management of severe falciparum malaria in pregnancy.

- Special concern must be paid to: anaemia -hypoglycaemia-pulmonary
oedema
- Quinine:
 First, second and third trimester and the puerperium
(throughout pregnancy + puerperium)
 Quinine dihydrochloride 10 mg/kg body weight 8 hourly
for 7-10 days. Given in intravenous infusion: 10% glucose
or 5% glucose in normal saline
 Rate of infusion:
o 15 drops per minute
o 2 ampules (1200mg)in 500ml infusion
o 1/2 the infusion in 4 hours

171
  Initially give the infusion 8 hourly for 3 days and then shift
to:
o Infusion 600mg 12 hourly
o OR Oral Quinine 600mg (2 tabs)8 hourly for 7 days.

Notice:
- Pregnant women usually do not tolerate oral Quinine and hence you
should give intravenous infusion for 7-10 days
- Random blood sugar should be done before and after quinine
administration.

Do the following 8 immediate measures:

1. Patent airway
2. Establish I.V line
3. Thick blood film for diagnosis
4. Assess dehydration clinically Assess fluid and electrolytes
requirements and correct
5. If temp is 38.50C or more use Tepid sponge and paracetamol (orally or
rectal supp)
6. Control convulsions: Diazepam I.V or rectal
7. Detect and treat hypoglycemia, 25-50% Dextrose, 50-100ml (1 ml /kg)
followed by 10% dextrose as continous infusion. Blood sugar 4-6
hourly.
8. Start I.V Quinine infusion.

Look and deal with the following 8 complications

1. Septicaemic shock or algid malaria: Systolic BP=> 80 mm Hg
- Third generation cephalosporin +I.V normal saline + hydrocortisone.
2. Anaemia: Packed cells transfusion :if Hb=> 5g/dl
3. Pulmonary oedema: Careful fluid management, back rest elevation,
Diuretics(40 mg I.V frusamide), oxygen.
4. Hypoglycaemia- as in above
5. Renal failure: could be pre-renal due to dehydration or renal due to severe
parasitaemia; strict fluid balance, diuretics and dialysis if needed
6. Spontaneous bleeding (DIC), GIVE FRESH BLOOD
7. Malarial haemoglobinuria: continue quinine +fresh blood.

172
 Management in labour
- Falciparum malaria and high fever induce uterine contraction resulting in
pre-term labour
- The frequency and intensity of contractions is related to degree of fever
leading to fetal distress
- Lower temp: Tapid sponge and Paracetamol
- Fluid management and fetal monitoring.

Antimalarial drugs in Pregnancy and Puerperium

GESTATIONAL UNCOMPLICATED SEVERE PREVENTION

AGE IN WEEKS MALARIA MALARIA
0-12 Quinine: Oral Quinine 2 tabs I.V infusion
(600mg) 8 hourly for 7-10 Quinine 600mg 8
days hourly for 7-10 day
13-Delivers - Oral Quinine 2 tabs I.Vinfusion 3 tabs SP
(600mg) 8 hourly for 7-10 Quinine 600 mg 8 (Fansidar and
days hourly for 7-10 again &after 4-
OR: Oral Quinine for 3 days days 6 weeks.
followed by SP (Fansidar)3
tabs
OR: As +SP
Ist day=3 tabs SP (Fansidar)
+2 tabs AS (Artesunate)
2nd day :2tabs AS
3rd day 2 tabs As
(Total 9 tabs :3 SP
(anisdar))+ 6 AS)
Puerperium AS+SP as above Quinine infusion -

Intermittent preventive treatment (IPT)

- Prevention of malaria and its consequences on mothers and newborns

- In high transmission areas (irrigated areas)
- Two doses of Sp (Fansidar)3 tabs regardless of parasitaemia of women
First dose: 16-20 weeks gestation
Second dose 4-6 weeks after first dose
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 GUIDELINES FOR THE MANAGEMENT OF EPILEPSY

Introduction
Women with epilepsy can present with convulsions in pregnancy. Like many like
many chronic diseases, epilepsy worsens in some women during pregnancy but
improve in others. In the majority of women, however epilepsy is unaffected by
pregnancy.

Observe the woman closely. In general, pregnant women with epilepsy have an
increase risk of:

-Pregnancy –induced hypertension;

-preterm labour;

-infant with low birth weight;

-Infant with congenital malformations;

-perinatal mortality.

Aim to control epilepsy with smallest dose of a single drug. Avoid drugs in early
pregnancy, which are associated with congenital malformations (e.g. valporic
acid).

If the woman is convulsing, give diazepam 10 mg slowly over two minutes.

Repeat if convulsion recurs after 10 minutes.

If convulsion continues, (status epilepticus) infuse phenytion 1 g approximately

18 mg \body weight) in 50-100 ml normal saline over 30 minutes (final
concentration not to exceed 10 mg per ml):

174
Note: only normal saline can be used to infuse phenytion. All other IV fluids
will cause crystallization of phenytion.

- Flush IV line with normal saline before and after infusing

phenytion.
- Do not infuse phenytion at a rate exceeding 50 mg per minute due
the risk of irregular heat beats, hypotension and respiratory
depression;
- Complete administration within one hour of preparation.

. If the woman is known to be epileptic, give her the same medication that she
had been taken. Follow-up her regularly by BP, pulse, respiratory rate and adjust
the dose of medication according to the response. .

. If the woman is known to be, epileptic but cannot recall details of her
medication; give her phenytion 100 mg by mouth three times per day.
Follow up with regularly and adjust the of medication according to her response.

. Anticonvulsant drugs may cause folic acid deficiency. Give folic acid 600 mcg
by mouth once daily along with antiepileptic treatment in pregnancy.

. Phenytion can cause neonatal deficiency of vitamin K-dependant clotting

factors. This can be minimized by giving vitamin K 1 mg IM to the newborn.

. Evaluation of underlying causes of convulsions indicated if convulsion of recent

onset.

PHYSICIAN OPINION

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GUIDELINES FOR THE MANAGEMENT OF BRONCHIAL ASTHMA IN
PREGNANCY

1. Introduction:
Asthma is one of the most common respiratory disorders in pregnancy. All
commonly used medications to control asthma are safe in pregnancy; steroids
are safe both for women and their fetuses. There is no evidence that there is
any significant impact of asthma on fetal growth or outcome, the control of
asthma should be at its optimum prior to onset of labour or caesarean section.
Attacks of asthma during labour are rare due to increased secretion of cortisol.

2. Definitions:
2.1. Asthma is a paroxysmal attack of an inflamatory condition
of airway involving many types of cells especially mast cells,
eosinophils and lymphocytes causing bronchospasm and mucus
secretion in the bronchial tree cause recurrent episodes of
wheezing, breathlessness, chest tightness and cough
2.2. Acute severe asthma: status asthmaticus.
It is a long lasting and severe asthma episode that does not respond
to standard management associated with severe respiratory distress
and arterial hypoxaemia (when asthma symptoms and signs fail to
improve).

3. Diagnosis
- Breathlessness, wheezes, cough could be productive), chest
tightness. All symptoms are increased with exertion and at night
- fall in Peak Expiratory Flow (PEF)
- Signs and symptoms of severe attack:
o Symptoms and signs persist or worsen despite adequate
management (muscle fatigue, speaks in short words, decrease
breathing sounds or silent chest, pulsus paradoxus, cyanosis,
tachycardia < 120 or bradycardia, Respiratory rate < 30/min)
o Increased medication requirement
o Low PEF

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 o Forced Expiratory Volume in one second FEV1> 60%
o Partial pressure of oxygen in arterial blood (PaO2) >60 mm Hg.
o Partial pressure of carbon dioxide in the blood(Pa CO2) < 42
mmHg.
4. Management:
The goal is to: Rapidly restore the functional status to its best level to
maintain optimum function.
- Admission to ICU
- IV canula
- Rest on a seated rather than supine position.
- High concentrated and flow oxygen (Saturation < 90% and Pa O2 < 60 mm
Hg)
- Repeated measurements of PEF and FEV1.
- Interpretation of arterial blood gasses

- Salbutamol inhaler via hand held nebulizer (can be given with oxygen)
2.5-5 mg diluted in 3-4 ml saline every 20 minutes/3 doses
(OR Continuously in very ill patient).
Then, 2.5-10 mg every 1-4 hours as needed.
Note: Beta2 agonists do not delay the onset of active labour or slow the
course of labour
- Inhaled ipratropium in combination with salbutamol.
- Hydrocortisone 100 mg iv 6 hourly (Taper as patient improves)
- Antibiotics as needed:
- drugs of choice I.V Cefuroxime and Erythromycin
- I.V fluids if patient is dehydrated (containing glucose if not
hyperglycaemic)
- Correction of hyperkalaemia (caused/exacerbated by B2 agonist or
steroids)
- Continue fetal monitoring

If Poorly or no response
- Salbutamol I.V 3-20 microgram/min
- OR: Aminophylline I.V 250 mg over 20 minutes.

If All above fails

- Heliox (helium mixture with oxygen)
- Mechanical ventilation (Respiratory failure or PEF> 30%)
177
- Indications for endotracheal intubation and assisted ventilation:
 coma
 exhaustion, confusion, drowsiness
 Deterioration of blood gasses
 Silent chest
 Respiratory failure

- Avoid the use of the following drugs (used commonly during labour) in
women with a history of asthma as they may precipitate severe
bronchospasm
o Ergometrine alone (except in severe PPH)
o Non –steroidal anti-inflamatory drugs e.g. diclofenac
o Beta – blockers such as labetalol for hypertension
o Prostaglandin F2 (carboprost/ Haemabate) for life threatening PPH.
o In chronic asthma, elective forceps/ventouse delivery may be
indicated .
o In caesarean section spinal or epidural anaesthesia.
If general anesthesia is required, the anaesthetic care is the same as
in non-pregnant.
o Breast feeding is safe with asthma medications.

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 GUIDELINES FOR THE MANAGEMENT OF ANAEMIA IN
PREGNANCY

1. Introduction
Anaemia is defined as a haemoglobin > 11 g/dl. It is a common
problem encountered during pregnancy, labour and puerperium.
The importance of anaemia during pregnancy is based on: (i) the
extra requirements of iron, folic acid, B12 and other nutrients
during pregnancy (ii) its treatment is limited by time since the
woman can go in labour at any time (iii) it predisposes to
premature delivery and IUGR (iv) anemic woman cannot tolerate
complications e.g APH, PPH. Anaemia is more common in
multiple pregnancy, frequent childbirth.

The commonest types in pregnancy are iron deficiency, folic acid

deficiency. B12 deficiency and haemoglobinopathies are less
frequently seen.

Daily requirements: Iron: 2.5-3.7mg in third trimester.

Folic acid =400 micrgrams.

B12 =3micrograms.

Fortunately anaemia is one of the few complications in pregnancy

which could be prevented.

2. Diagnosis:
- Clinical: vague symptoms of tiredness, pallor
- Laboratory:
Hb: At first visit and repeated at 28 weeks and 36
weeks

Complete Blood Count: Preferred to Hb if available.

Total Iron Binding Capacity.

Serum iron

179
 MCV. PCV, serum ferritin (most sensitive single
test – 30 micrormas/L, has a sensitivity of 90%).

Peripheral blood picture.

: Electrophoresis.

3. Management
3.1. Prevention: when Hb ≥11g/dl

- Iron=30-60mg (elemental iron) per day.

- Folic acid =400 u g pre day (3 months prior to
pregnancy and throughout).
3.2. Treatment:

3.2.1. Oral iron: EFFECTIVE, FIRST CHOICE.

- 200 mg elemental iron per day.

- Ferrous gluconate: 300mg/day.
- Ferrous fumerate: 200 mg/day.
- Ferrous sulphate : 200 mg/day.
3.2.2. Intramuscular iron: NOT SUPERIOR TO ORAL IRON.
- Given only if the patient has intolerable side-effects
(nausia + vomiting) or has malabsorption.
- Iron sorbitol citric acid complex e.g. jectofer or ferrum:
Ampule = 2ml. Each ml contains 50 mg elemental iron.
Given I.M deeply. 2 ml every other day for 10 days or
longer.
- Side-effects: pain, disoloration of skin, allergy.
3.2.3. Folic acid:
- 5 mg per day.
3.2.4. Blood transfusion:
- Indicated only in severe anaemia > 7g/dl during pregnancy or
puerperium.
- Packed cells ONLY at intervals.
3.2.5. B12:
- Single dose of 1000 microgram I.M/week until anaemia is
resolved. Then for life.
180
 GUIDELINES FOR THE MANAGEMENT OF DEEP VEIN
THROMBOSIS AND PULMONARY EMBOLISM DURING PREGNANCY
AND PUERPERIUM

1. Introduction:
Venous thromboembolism (VTE) is a serious complication during
pregnancy and the puerperium and it is the leading cause of
maternal death in developed countries. In Wad Medani Hospital
the incidence is higher in the puerperium than antenatal and very
few develop pulmonary embolism. However as a cause of maternal
death it ranks after haemorrhage, hypertensive disorders, sepsis and
viral hepatitis. VTE is up to 10 times more common in pregnancy
than in non pregnant subjects. Deep venous thrombosis (DVT)
usually occurs in the ileo-femoral veins, the calf veins, the thigh
veins. It is more likely to occur in the LEFT leg due to
compression of the left iliac vein by the right iliac artery.
These guidelines help doctors to identify at risk patients, prevent
and treat VTE

2. The pathogenesis of pregnancy associated VTE:

- VTE is 10 times more common in pregnant than non-pregnant
subjects due to certain changes which occur in All pregnant
women.
2.1. Hypercoagulability
- Increased: von Williebrand factor, VII, IX, X, XII
and fibrinogen.
- Reduced protein S, protein C and impaired fibrinolytic
activity

2.2. Venous stasis:

Due to pressure of the gravid uterus on the inferior vena cava and
the pressure of the left common iliac vein by the right ilic artery.

181
 2.3. Vascular damage to pelvic veins during vaginal delivery
and caesarean section.

3. Risk factors for VTE.

Age < 35, immobility, obesity, caesarean section and all
instrumental deliveries, pre-eclampsia, parity < 4, previous DVT,
excessive blood loss, sickle cell disease, paraplegia, infection,
dehydration, thrombophilia (congenital: antithromin deficiency,
protein C deficiency, protein S deficiency, factor V Leiden.
Acquired: Lupus anticoagulant, anticardiolipin antibodies).

4. Diagnosis of DVT
- Symptoms and signs:
- Leg pain or discomfort (Especially left)
- Loss of function. limbing
- Swelling: Circumference 2 cm more than the normal
- Tenderness (calf, thigh, groin, sole of foot)
- Increased temperature and oedema
- Lower abdominal pain
- Elevated white cell count.
- Real time/Duplex ultrasound
- If Negative +low level of clinical evidence discontinue
anticoagulant
- If Negative +high level of clinical evidence continue
anticoagulant.

5. Diagnosis of Pulmonary Embolism (PE)

- Symptoms and signs:
Dyspnoea, collapse, chest pain, haemoptesis, faintness, Raised
JVP, focal chest signs, DVT.

- Ventilation/Perfusion (V/Q) lung scanning and bilateral duplex U/S

of both legs.
- CT,MRI, Pulmonary angiography.
- X-ray chest:
30% normal; may show atelectasis (collapse) or
elevated diaphragm.
182
 6. Treatment of VTE in Pregnancy:
- Both Unfractionated Heparin (UFH) and Low Molecular Weight
Heparin (LMWH) do not cross the placenta and are not associated
with teratogenicity and hence could be given throughout
pregnancy.

- Warferin crosses the placenta

- First trimester= embryopathy
- Fetal and neonatal haemorrhage, death
- The drug is contra- indicated in pregnancy EXCEPT IN
PATIENTS WITH PROSTHETIC VALVES.
- warferin can be used postpartum.
- UFH can cause bleeding, thrombocytopenia and osteoporosis. It is
followed up by:
- Activated Partial Thromoplastin Time APTT of 1.5-2.5
times control.
- Platelets count every 2-3 days from day 4 of start.
- LMWH: less bleeding, less thrombocytopenia. Routine platelet
count follow-up is not required.
- Both UFH and LMWH can cause allergy; itchy erythematous
lesions at the injection site. In this case change the preparation or
switch from LMWH to UFH.

Treatment regimen VTE in pregnancy:

START ANTCOAGULANT THERAPY IMMEDIATELY AFTER
CLINICAL DIAGNOSIS AND THEN CONFIRM OR OTHERWISE BY
DUPLEX U/S.

Unfractionated Heparin (UFH)

10,000 IU I.V 6 hourly for 5-10 days or until symptoms and signs
subside.
- Then follow with a fixed dose 5000 IU subcutaneously 8 hourly.
- OR 10,000 IU subcutaneously 12hourly throughout pregnancy till
delivery. Stop 24 hours before vaginal delivery or caesarean
section and then commence 24 hours postpartum.

183
 - Monitor by activated partial thromboplastin time (APTT) 6 hourly
during the first 24 hours until the APTT is within the theraputic
dose (1.5-2.5 times the control value) and then monitor by APTT
daily.

OR:LMWH:
- As safe and as effective as UFH in both treatment and prevention
of VTE.
- Preferable to UFH because of: Ease of administration, lower risk
of bleeding and thrombocytopenia.

- Enoxaparin I mg/Kg twice daily for at least 6 months and until at

least 6 weeks post-partum.

- Monitoring is not required

- In massive life threatening PE use UFH and streptokinase.

7. Treatment regimen of VTE post partum

- UFH 10,000 IU IV bolus 6 hourly for 5-10 days or until symptoms
subside.
- Then follow with a fixed dose 5000 IU subcutaneously, 8 hourly or
10,000 IU 12 hourly for 6-12 weeks
- Monitor by APTT.
- Or: Add warferin 2-5 mg (usually 2.5mg) during the last 3
days of intravenous heparin and continue warfenin for 3
months.

Monitor warferin by PTT and INR (WITHIN THE THERAPUTIC dose

INR=1.5-2.5)

8. Prophylaxis of thromboembolic disease in pregnancy

8.1. Only one previous episode of DVT or PE No other

risk factors.
8.1.1 – Low dose Asprin 75 mg daily.
184
 - OR UFH 5000-10,000 IU every 12 hours
subcutaneously

OR LMWH
- Enoxaparin 40 mg subcutaneously daily
- OR Dalteparin 5000 units daily
8.1.2. - Begin when pregnancy is diagnosed
- Continue until delivery
- After delivery switch to subcutaneous UFH or
LMWH
- Continue heparin for 6 weeks or switch to
warfenin after 2-7 days and continue for 6
weeks.

8.2. More than one episode of DVT or PE or one episode

plus a risk factor
8.2.1. - UFH- 5000 IU - 10,000 IU 12 hourly
- OR LMWH
o Enoxaparin 40mg daily
o OR Dalteparin 5000 units daily

8.2.2 Begin when pregnancy is diagnosed

After delivery continue heparin for 6-12 weeks or switch to
warferin for 6 weeks.

9. Prophylaxis of VTE post partum

9.1. Indications
- ALL CAESAREAN SECTION ELECTIVE AND
EMERGENCY
- All instrumental deliveries
- Vaginal delivery plus a risk factor e.g. Obese,
previous VTE.

9.2. Drugs
- UFH 5000 IU 8 hourly subcutaneously for 5-7 days.

- OR.LMWH twice daily for 5-7 days

185
 9.3. Early mobilization an hydration.

Amniotic Fluid Embolism (AFE)

Causes /Risk factors:

- Uterine tachycystole
- Syntocinon hyperstimulation
- Previous uterine surgery
- Multiparty
- Polyhydramnios

Clinical Features:
- Resless, shortness of breath and cynosis
- Vaginal bleeding follows within 30 minutes due to DIC.
- Nausia, vomiting
- Convulsions in up to 30%
- Unexpected cardiovascular collapse
coma death
- Progression can be very rapid.

Diagnosis:
- Based on clinical features
- CBC, Blood gases
- Coagulation screening, urea and electrolytes and
creatinine

Differential diagnosis:
- massive PE
- Bilateral pneumothorax
- Myocardial infarction
- Uterine rupture or inversion
- Septic shock
- Eclampsia

186
Management:
- initial management =ABC
- Two large I.V canulae
- Urine output monitor via catheter
- Portable CXR and ECG
- Invasive haemodynamic monitoring
- PEEP, dopamine frusamide, fluids
- Oxygen +ventilate
- Hydrocortisone 200 mg I.V aminophylline, adrenalin.
- Deliver baby as soon as possible
- Multidisciplinary
Obstetrician, anesthetist hematologist
- ICU
- Watch for sever PPH

187
GUIDELINES FOR THE MANAGEMENT OF HEART DISEASE IN
PREGNANCY

1. Introduction:
Although heart disease in pregnancy is rare, it continues to be one of the
important causes of maternal mortality and morbidity. The incidence of
causes of heart disease in pregnancy is changing; rheumatic fever is
declining while more women with congenital heart disease (corrected) and
myocardial infarction and cardiomyopathy are seen during pregnancy.
However rheumatic heart disease-MITRAL STENOSIS-continues to be
the most frequent cause in pregnant women in the Sudan.
Recently tremendous advancements in cardiac surgery have been made
and hence they should be included in the guidelines of management.

2. Physiological changes in pregnancy, labour and delivery:

- Blood volume: increases by 35%.
- Plasma volume: increases by 40%.
- Heart rate: increases by 10-20 beats per minute.
- RBCs mass: increases by 18%.
- Peripheral vasodilatation leading to drop in blood pressure which
returns to pre-pregnant value at term.

- Cardiac output: increases very early in pregnancy due to fall in

peripheral resistance and increase in stroke volume.
- Increase by 40% and continues till term.
- Further increase in first stage of labour (15%).
- Third stage: rise by 60-80% due to:
o Approximately 1 litre of blood returns to the circulation due
to relief of obstruction on the inferior vena cava and
contraction of uterus
o The patient is more at risk of developing pulmonary
oedeme in the second stage and immediate post partum.
o Supine position reduces cardiac output by 25%

188
 - Serum colloid osmotic pressure: decreases. Pregnant women are
more susceptible for pulmonary oedema (I.V fluids or pre-
eclampsia).

3. Possible cardiovascular finding in normal pregnancy

Loud first heart sound, third heart sound, systolic ejection murmur at the left
sternal age, ectopic beats.
- ECG: small Q and small T

4. Investigations:
- All investigations should be done if indicated
i. X-ray chest: negligible radiation to fetus
ii. ECG, Echo, CT and MRI are safe.

5. The outcome and safety of pregnancy are related to

- Pulmonary hypertension
- Cynosis
- Significant lesion
- New York Heart Association Grade < II
- Left ventricular ejection fraction > 40%
- Arrhythmias.

New York Heart Association Grading

I :Signs and no symptoms
II: Dyspnea on ordinary activity
III: Dyspnea on minimum activity
IV: Dyspnea at rest.

6. Aetiology
6.1 Rheumatic, 6.2 Congenital, 6.3 Coronary , 6.4 Cardiomyopathy

6.1.RHEUMATIC HEART DISEASE: MITRAL STENOSIS

(COMMONEST):
6.1.1.-Diagnosis:
- Asymptomatic mitral stenosis (may deteriorate post partum)
- Dyspnea, palpitations, syncopy, cough, haemoptesis, chest
pain, oedema
- Pulse: sinus tachycardia, atrial fibrillation
189
 - Blood pressure
- Tapping cardiac impulse, diastolic thrill, loud first heart sound,
rumbling mid diastolic murmur
- Base of lungs for crepetations
- ECG: left atrial P wave
- X-ray chest: small heart, pulmonary congestion or oedema

6.1.2. Consult cardiologist (joint management)

6.1.3. Avoid factors precipitating cardiac failure:
- Sinus tachycardia due to: pain, anxiety, exercise, exertion,
infection, fever, anaemia, preclampsia.
- Arrhythmias, increased cardiac output, endocarditis.

- Sinus tachycardia leading to decrease in stroke volume which leads

to rise in left atrial pressure and finally pulmonary edema. Treat by
Beta blockers which can cause fall in heart rate rise in stroke
volume fall in left artial pressure Dyspnoea settles.
6.1.4 Await spontaneous labour which is usually easy
- Induction of labour is contra-indicated (oxytocin and I.V fluids
may precipitate failure
- Heart disease is not an indication of caesarean section and is not a
contra-indication for caesarean section if there is an obstetric
indication

6.1.5. Labour:
- Spontaneous labour
- Fowlers position
- Partogram; avoid prolonged and obstructed-labour
- Avoid repeated vaginal examination
- Facial oxygen if needed
- Analgesia-100mg pethidine
- frusamide, hydrocortisone, aminophylline should be readily available
- strict fluid balance
- Prohpylactic antibiotics: 3 doses of third generation cephalosporin 1g and
gentamycin 120mg 8 hourly.
- Prostaglandins: little effect on heart disease.
- Ergometrine: Vasoconstrictor, contra-indicated.

190
 - Syntocinon infusion: Vaso dilatation and fluid retention (may precipitate
heart failure)
Tocolytics: contra-indicated

- Second stage: Expect easy delivery (usually small baby) but if

signs of prolonged second stage, deliver by forceps.
- Third stage: Ergometrine conta-indicated.use I.M oxytocin 5 IU
(Could be given in life-threatining PPH).

6.1.6 Postpartum:
- THE IMMEDIATE POST PARTUM AND FIRST 12 HOURS
AFTER DELIVER ARE THE MOST CRITICAL FOR
DEVELOPMENT OF PULMONARY OEDEMA.
- Keep patient in the labour room for 24 hours.
- Monitor hourly: pulse, PB, respiratory rate, basal crepetations,
uterus, bleeding.
- Give 40 mg frusamide
- Continue antibiotics
- Breast feeding.

6.1.7 PULMONARY OEDEMA

- Can occur during pregnancy, but usually during the second stage of
labour and immediate postpartum
- Caused by precipitating factor or unwise fluid I.V
- Mitral stenosis may be diagnosed for the first time postpartum
(increase in severity since last delivery or missed during ANC).
- Diagnosis:
 A terrifying experience, fighting for breath
 Dyspneoa-rapid respiration
 Distressed, agitated, sweaty, pale, unable to speak.
 Cough, haemoptesis, wheeze
 Tachycardia
 Extensive crepetations and rhonchi
 Hypotension, cardiac arrest .

191
 TREATMENT: (Inform cardilogist)
- Sit the patient up to reduce pulmonary congestion
- Oxygen (high flow, high concentration) using a tight fitting face
mask.
- Furosomide (lasix) - 40-80 mg intravenous
- Morphine (10mg I.V). May be cautiously used. It reduces
sympathetically mediated peripheral vasoconstriction, but may
cause respiratory depression.
- I.V glyceryl trinitrate 10-200 ug per minute until clinical
improvement or systolic BP > 110 mm Hg. It is a venous and
arteriolar dilator. Venous dilatation reduces right ventricular out
put. Arteriolar dilatation improves left ventricular function by
reducing after load.
- If the above measures fail, use inotropic agents e.g dopamine.
- If all fail there is an indication for cardiac surgery.

6.2. Mechanical heart valves:

- Most women with prosthetic valves have sufficient cardiovascular reserve to
accomplish pregnancy safely.

- Life long anticoagulant

o Warferin: usually less than 5 mg
o Do not change to heparin during pregnancy. (warferin throughout
pregnancy, puerperium and for ever)
o Warfenin can cross the placenta and cause; embryopathy, abortion,
stillbirth or cerebral haemorrhage.

o Stop 24 hours before delivery or caesarean section and continue the

second day
o If the patient develops bleeding or needs urgent delivery, give fresh
blood, fresh frozen plasma and Vit K.
Note: There is an increased risk of thrombosis if you change from warferin to
heparins even if given in full anticoagulant dose. Heparin lacks an agreed optimal
test and may cause thrombocytopenia.

6.3. Coronary artery disease: Rare

- Myocardial infarction without preceding angina because the underlying
cause is non-atherosclerotic. It is due to coronary thrombosis.
192
 - Presents with severe chest pain
- Risk factors: multipara, obese, diabetic, hypertension.

- Diagnosis and treatment as in non-pregnant

o Coronary angiography should be done
o Thrombolysis, stent, Asprin and B-blocher
o All should be given as indicated.
o Statins: contra-indicated

6.4. Peripartum cariomyopathy

- Definition:
Development of cardiac failure between the last month of pregnancy
and 5 months postpartum in the absence of an identifiable cause or
recognizable heart disease prior to the last month of pregnancy and left
ventricular systolic dysfunction demonstrated by the following
echocardiographic criteria
- left ventricular ejection fraction > 45%
- fractional shortening > 30%
- Dilatation of all cardiac chambers and left ventricular
hypokinesia.
- Risk factors: multiple pregnancy, hypertension (both chronic and
pre-eclampsia) multiparity, old age, African race.

- Diagnosis:
o Breathless, tachycardia, chest pain, heart failure (no valvular
lesion or Myocardial infarction
o X-ray chest: Enlarged heart
o Echo: Dilated chambers.

- Differential diagnosis
o Pulmonary embolism (Echo excludes PE)
o Myocardial infarction
- Treatment:
o Facial oxygen
o Frusamide 20-40 mg I.V
o Angiotensin Converting Enzyme Inhibitor (ACE)
o Heparin prophylaxis 5000 IU 8 hourly 5-7 days
193
 o Digoxin if there is fibrillation.
o 50% recover but can recur in next pregnancy.

6.5. Arrhythmia
Supraventricular tachycardia Give Propranplol

6.6. Congenital heart disease

- Baby may have congenital heart disese

- Acynotic:
Atrial Septal Defect (ASD):
Commonest in pregnancy. No problems in pregnancy. Acute
blood loss is poorly tolerated, therefore correct it.

Cyanotic:
Tetralogy of Fallot
- (Righ ventricular hypertrophy +pulmonary stenosis+ over riding of aorta
+VSD)
- Pregnancy tolerated
- IUGR, abortion, preterm labour
- Prophylactic antibiotics and heparin.

Eisenmenger syndrome:
- High maternal mortality
- Advice against pregnancy.

194
 GUIDELINES FOR MANAGEMENT OF SICKLE CELL DISEASE

Introduction:
This is a rare genetic abnormality which may be encountered during
pregnancy and childbirth, however it is associated with significant maternal
and fetal complications. Junior doctors are usually not familiar with sickle cell
disease in pregnancy. These guidelines help doctors manage pregnant women
with sickle cell disease safely.

Diagnosis:
1. Sickle cell disease
Anaemia, positive sickle test, haemoglobin electrophoresis HbS
HbF No HbA Microcytic anaemia

2. Sickle cell trait

No change in hematological indices, Positive sickle test,
Haemoglobin electrophoresis= HbA + HbS HbAS.

Clinical features:
- Characterized by crises precipitated by infection, dehydration and
hypoxia.
- Crises
1. Vasoocclusive crises: bones
2. Visceral: liver spleen
3. Aplasia: rapid developing anaemia
4. haemolytic
5. Leg ulcers
- Repeated crises
o Bone deformity, osteomylitis, renal failure, leg ulceration,
myocardial infarction, gall stones, cardiac feature.
o Repeated blood transfusion leading to iron overload and
infection.

195
Maternal Risks:
- Venous thromboembolism (VTE)
- Pre-eclampsia
- Urinary tract infection
- Pneumonia
- Abortion
- Placental abruption
- Anaemia

Fetal Risks:
- Pre-maturity: Ante partum steroids
- Intra uterine growth retardation (IUGR)

Management:
1. Monthly urine analysis. Prompt treatment of urinary tract infections.
2. Complete blood count (CBC) monthly to detect severe anaemia
3. Folic acid throughout pregnancy for all women 5 mg per day
4. Avoid iron supplementation as a routine unless there is proven iron
deficiency anaemia.
5. Blood transfusion indications
o Severe anaemia Hb > 5g indicating a haemolytic crisis
o Falling reticulocyte count indicating impending aplasia.
o Pre-eclampsia
o Septicaemia
o Acute renal failure
o Multiple pregnancy
o Preparing for caesarean section

Blood transfusion
- If haemoglobin is > 59 top up transfusion
- If haemoglobin is 8-10 g Exchange transfusion
(Remove 500ml while transfusing 2 units packed cells)

6.Treatment of thrombotic painful crisis

- Pain relief: Diclofenac intramuscular.
- Treat infection: Cephalosporin
196
 - Oxygen: Facial mask
- Hydration:IV.5% Dextrose saline
- Thromboprophylaxis: Heparin 10,000 I.V 6 hourly for 5-7 days

7.Intra-partum management
- Keep patient warm
- Good hydration I.V fluids 500 ml 5% Dextrose saline 4 hourly
- CBC; prepare blood
- Monitor: pulse, BP, temp, respiration: hourly
- Facial oxygen
- Fluid chart (input-out)
- Pain relief: Pethidine 100 mg im
- Avoid general anaesthesia
- Prophylactic antibiotics: Cephalosporin
- Avoid prolonged labour and always consider caesarean section
- Active management of third stage.

8.Post partum management

- Cord blood for electrophoresis
- Maintain hydration +oxygen for 24 hours
- Prophylactic antibiotics: cephalosporin 5 days
- Prophylactic heparin:5000 Iu subcutaneous 12 hourly for 7 days
- Early recourse to blood transfusion for excessive post partum loss
- Watch closely for postpartum crisis.

197
References:
1. A.A.Calder:Normal Labour.In:D.Kieth Edmonds (ed) Dewhurst Textbook
of Obstetrics and Gynaecology.7th edition. Blackwell Publishing.Oxford
2007.46-55
2. S.Arulkumaran: Malpresentation, malposition, cephalopelvic disproportion
and Obstetric procedures. In:D. Kieth Edmonds (ed) Dewhurst Textbook
of Obstetrics and Gynaecology. 7th edition. Blackwell Publishing. Oxford.
2007. 213-226.
3. Thacker SB and stroup DF, Continuous electronic heart rate mom
monitoring versus intermittent auscultation for assessment during labour
(Cochran Review). In:Cochrane Library, Issue 3, 1999. Oxford:Update
software. (Level 1)
4. Fraser WD, Krauss 1, Brisson-Carrol G, Thornton J, Breat G.Amniotomy
for shortening spontaneous labour (Cochrane Review).In: theCochrane
library, 4,1999.Oxford:Update Software (level 1).
5. Frigoletto FD et.al.A clinical trial of active management of labour. NEJM
1995:333: 745.(level 1).
6. Roogers R et.al. Active management of labour: does it make a difference?
Am J Obstet Gynecol 1997 Sep;177(3):599-605.(Level 1).
7. Fraser W, vendittelli F, Krauss 1, Breat G. Effects of early augmentation
of labour with amniotomy and oxytocin in nulliparous women: a meta
analysis. Br J Obt Gyn 1998 Feb; 105 (2): 189-94.(Level 1).
8. Friedman, EA and Sachtleben MR. Dysfunctional labour: 1. Prolonged
latent phase in the multipara. Ob Gyn Feb 1961; 17(2): 135-148.(Level II)
9. Hofmeyr GJ, Kulier R. External cephalic version for breech presentation at
term (Cochrane Review).In:The Cochrane Library, Issue3, 1999. Oxford:
Ubdate Software.(Level1).
10. External Cephalic Version, ACOG Practice Bulletin, Feb.2000:No.13:1-6
(Level III).
11. Hofmeyr GJ. External Cephalic version facilitation for breech presentation
at term. The Cochrane Library, Issue 1,2000.Oxford:Update
Software.(Level 1).
12. Hofmeyr GJ, Hannah ME.Planned Caesarean section for term breech
delivery (Cochrane Review). In: the Cochrane Library, Issue1,
2000.Oxford: Update Software (level 1).

198
13. Eclampsia trial collaborative group. Which anti-convul sant for women
with eclampsia? Evidence from the collaborative trial. Lancet 1995;
345:1455-63.(Level 1).
14. Lucas MJ,Leveno KJ,Cunningham FG. A comparison of magnesium
sulphate with phenytoin for the prevention of eclampsia. New Engl J Med
1995;333:201-5.(Level 1).
15. American Academy of Pediatrics: Human immunodefiency
immunodeficiency virus screening: Joint statement of the American
Academy of Pediatrics and the American College of Obstetricians and
Gynaecologists. Peadiatrics 1999:104:128 (Level III).
16. American College of Obstetricians and Gynaecologists. Hypertension in
Pregnancy. ACOG Technical Bulletin no 219. Washington, D.C: ACOG,
1996(Level III).
17. Magann EF, Martin JN. Twelve steps to optimal management of HELLP
syndrome. Clinical Obstet Gynecol 1999; 42:532-50 (Level III).
18. Toglia MR, Weg JG. Venous thromboemboembolism during pregnancy. N
Engl J Med J Med 1996:335: 108-14 (Level III)
19. De Swiet M.Management of pulmonary embolism in pregnany.European
Heart Journal 1999: 20:1378-85.(Level III).
20. Greer, IA. Thrombosis in pregnancy and fetal issues. Lancet 1999;
353:1258-65.(Level III).
21. Andrew shennan: Hypertensive disorders. In:D.Kieth Edmonds
(ed)Dewhurst Textbook of Obstetrics and Gynaecology. 7th edition.
Blackwell publishing. Oxford 2007 227-235.
22. The Magpie Trial Collaboration G 92002) Do women with pre-eclampsia,
and their babies, benefit from magnesium sulphate The Magpie Trial; a
randomized placebo-controlled trial. Lancet 359(9321). 1877-90.
23. P.Clark, A.J.Thomson and I.A.Greer.Haematological problems in
pregnancy. In:D.Kieth Edmonds (ed) Dewhurst text book of obstetrics and
Gynaecology. 7th edition. Blackweel Publishing. Oxford 2007.270-281.
24. Mahmood K(2004) Prophylactic versus selective blood transfusion for
sickle cell anaemia in pregnancy (Cochrane Review). The Cochrane
Library. Chichester, UK:John wiley and Sons Ltd.
25. Greer I and Thomson A (2001) Management of uenous thromboembolism
in pregnancy. Best Pract Res Clin Obstet Gynaecol 15, 583-603.
26. Chan W, An and S and Ginsbreg J(2000) Anticoagulation of pregnant
women with mechanical heart valves: a systematic review of the literature.
Arch Int Med 160, 191-6.
199
27. Thomson A and Greer I (2001) Thromboembolic disease in pregnancy and
the puerperium: acute management. RCOG Guidelines No 28.
London:RCOG Press.
28. Greer I and Nelson-Piercy C (2005) Low molecular weight heparin for
thromboprophylaxis and treatment of venous thromboembolism-a
systematic review of safety and efficacy. Blood 106, 401-7.
29. Phillip Bennet: Preterm labour. In:D.Kieth Edmonds (ed) Dewhurst
textbook of Obstetrics and gynaecology. 7th edition.Blackwell Publishing.
Oxford.2007 177-191.
30. Crowley P.Corticosteroids after pre-term premature rupture of membranes.
31. Crowley P.Prophylactic corticosteroids for pretern birth(Cochrane review),
In:The Cochrane Library, Issue 3,2000.Oxford. Update software. (Level I).
32. American college of Obstetricians and Gynaecologists. Premature rupture
of membranes. Practice Bulletin No 1 June 1998 (Level III).
33. Tan BP, Hannah ME. Oxytocin for prelabour rupture of membranes at or
near term. Cochrane Review Vol 1999:Oxford: update Software,
1999(Level 1)
34. Hauth JC, Goldenberg RL, Andrews WW, DuBard MB, copper RL.
Reduced incidence of preterm delivery with metronidazole and
erythromycin in women wih bacterial vaginosis. The New England Journal
of Medicine 1995; 333:1732-1736 (Level 1).
35. The National Protocol for Treatment of Malaria. June 2004. National
Malaria control programme-fedral Ministry of Health Sudan.
36. McDonald S, Prendaville WJ, Elbourne D, Active versus expectant
management in the third stage of labour (Cochrane Review). In: The
Cochrane Library, Issue 2, 2000.Oxford:Update Software.
37. Soriano D, Dulitzki M, Schiff E, et.al. A prospective cohort study o
oxytocin plus ergometrine compared with oxytocin alone for prevention of
postpartum haemorrhage. Br J Obstet Gynaecol 1996; 103: 1068-73.
38. Sara Paterson-Brown. Obstetric emergencies. In: D. Keith Edmonds (ed)
Dewhurstُs Textbook of Obstetrics and Gynaecology. 7th edition.
Blackwell Publishing. 2007.Oxford 145-158.
39. Black RS and Brocklehurst P(2003)A systematic review of training in
acute Obstetric emergencies. Br J Obstet Gynaecol, 110, 837-41.
40. Baglin T (1996).Disseminated intravascular coagulation: diagnosis and
treatment. Br Med J, 312, 683-7.
41. Penna L and Clarke Y(2003). Postpartum collapse Curr Obstet Gynaecol,
13, 67-73.
200
42. Ferguson JE, Bourgeois FJ and Under wood PB (2000).B-Lynch suture for
postpartum haemorrhage Obstet Gynaecol, 95, 1020-2.
43. G.Justus Hofmeyr. Induction and augmentation of labour. In:D.Keith
Edmonds (ed) Dewhurstُs textbook of Obstetrics and Gynaecology. 7th
edition. 2007. Blackwell Publishing. Oxford 205-212.
44. Royal College of Obstetricians and Gynaecologists (RCOG)
(2003).Induction of labour. Evidence- based clinical Guideline
(no9).London: RCOG Press.
45. Hofmeyr GJ and Gulmezoglu AM (2002) Vaginal misoprosto for cervical
ripening and induction of labour (Cochrane Review). The Cochrane
library. 1 CD000 941.
46. Hofmeyr GJ, Alfirevic Z, Kelly T et.at.(2001)Methods for cervical
ripening and labour induction in late pregnancy:generic protocol (Protocol
for a Cochrane Review). The Cochrane Library 4, CD002074.
47. Eason E.,Labrecque M, wells G, Feldman P. Preventing perined trauma
during childbirth: A systrmatic review. Obstetrics and Gynaecology.
95(3):464-71,2000 Mar.(Level 1).
48. Goswami K, Young P, Grady K and Cox C (2003). Amniotic fluid
embolism. In: Johanson R, Cox C, Grady K and Howel C (eds). Managing
Obstetric emergencies and Trauma: The MOET course Manual.
London:RCOG Press, 29-34.
49. Grady K and Cox C (2003( Triage. In: Johanson R, CoxC, Grady K and
Howel C (eds) Managing Obstetric emergencies and Trauma. The MOET
course Manual. London:RCOG Press, 275-7.
50. Mc Farland et at, Perinatal outcome and the type of maneuvers in shoulder
dystocia. Int Journal Gynecol Obstet 55; 219-24,1996(Level III)
51. Gheman et al. The McRoberts Maneuver for alleviation of shoulder
dystocia, how successful is it. Am J of Obstet Gynecol 1997; 176; 656-61
1997 (Level III).
52. Ramsey PS, et al.Shoulder dystocia: Rotational maneuvers revisited, J
Repord Med 2000; 45:85-88 (Level III).
53. World Health Organization.Managing complications in pregnancy and
childbirth 2000, reprinted 2007, Geneva, 51-53.
54. ACOG Practice Bulletin (2000) Operative Vaginal delivery. Clinical
management guidelines for the Obstetrician Gynaecologist number 17,
june 20.

201
55. Operative vaginal delivery ACOG Practice Bulletin No17. June 2000.
American College of Obstetricians and Gynaecologists.
Washington,D.C.(Level III).
56. Johanson RB, Menon VY.Vacuum extraction versus forceps for assisted
vaginal delivery (Cochrane Review). In: The Cochrane Library, Issue 1,
1999. Oxford: Update Software (Level 1).
57. Managing complications in pregnancy and Childbirth WHO 2002.
58. RCOG guidelines, operative vaginal delivery 2005.
59. Smaill F, Hofmeyr GY. Antibiotic prophylaxis for Caesarean section
(Cochrane Review) In: the Cochrane library, Issue 1, 2000.Oxford:Update
software (Level l).
60. Hopkins L, Smaill F. Antibiotic prophylaxis regimens and drugs for
caesarean section (Cochrane Review).In :The Cochrane Library, Issue 1,
2000. Oxford:Update Software (Level 1).
61. Wilkinson C, Enkin MW. Manual removal of the placenta at caesarean
section (Cochrane Review) in: the Cochrane Library, Issue 1,2000.
Oxford:Update Software. (Level 1).
62. Wilkinson C, Manual removal of the placenta at caesarean section
(Cochrane Review)In: The Cochrane Library, Issue1, 2000.
Oxford:Update software. (Level1).
63. Wilkinson C, Enkin MW. Uterine exteriorization versus intraperitoneal
repair at caesarean section. (Cochrane Review). In: The Cochrane Library,
Issue 1, 2000. Oxford: Update Software (Level 1).
64. Wilkinson C,Enkin MW. Peritoneal non-closure at caesarean section
(Cochrane Review). In: The Cochrane Library, Issue 1,
2000.Oxford:Update software (Level 1).
65. Hofmeyr GJ, Hannah ME. Planned Caesarean section for term breech
delivery (Cochrane Review). In: The Cochrane Library, Issue 1, 2000.
Oxford: Update Software (Level 1).
66. Nicholas M.Fisk.Multiple Pregnancy.In:D,Keith Edmonds (ed)
Dewhurstُs Textbook of Obstetrics and Gynaecology.7th
edition.Blackwell Publishing 2007.Oxford.166-176
67. Kilby MD,Baker P,Critchley H, Field D (eds) (2006) Multiple
Pregnancy:Proceedings of the RCOG study group.London:RCOG Press.
68. Davor Jurkovic.Ectopic pregnancy.In: D.Keith Edmonds (ed) Dewhurstُs
Textbook of Obstetrics and Gynaecology. 7th edition. Blackwell
Publishing 2007.Oxford.106-116.

202
69. Royal College of Obstetricians and Gynaecologists (2004).The
management of tubal pregnancy. Guideline 21.London:RCOG Press.
70. Hajenius PJ,Mol BWJ,Bossuyt PMM,Ankum WM,Van der Veen F.
Interventions for tubal ectopic pregnancy(Cochrane Review)In:Cochrane
Library, Issue 2, 2000.Oxford:Update Software.(Level 1)
71. The management of gestational trophoblastic disease neoplasia RCOG
Guidline No38.
72. Soper JJ, Mutch DG, Schink JC (2004) American College of Obstetricians
and Gynaecologists, Diagnosis and treatment of gestational trophoblastic
disease:ACOG,Practice Bulletin No.53, Gynecal, Oncol.93,575-85.
73. Anne Dornhorst and Catherine Williamson Diabetes and endocrine disease
in pregnancy. In:D.Keith Edmonds (ed) Dewhurstُs Textbook of
Obstetrics and Gynaecology.7th edition 2007Blackwell Publishing Oxford
246-529.
74. Clinical management guidelines or Obstetrician gynaecologist, Feb 2008.
75. National asthma education and prevention programm. Expert Panel Report
III.Guidelines for the diagnosis and management of asthma
76. Catherine Nelson-Piercy.Heart Disese in pregnancy.In:D.Keith
Edmonds(ed)Dewhurstُs Textbook of Obstetrics and Gynaecology 7th
edition 2007.Blackwell Publishing Oxford 236-245.
77. Peasron GD, Veille JC, Rahimtoola S et al. (2000)Preipartum
cardiomyopathy. National Heart, Lung and Blood Institute and Office of
Rare Diseases (NIH). Workshop Recommendations and Review. J Am
Med Assoc 283,1183-88.
78. Koshy M(1995)Sickle cell disease and pegnancy.Blood Rev 9, 157-64.
79. Mahmood K (2004) Prophylactic versus selective blood transfusion for
sickle cell anaemia during pregnancy(CochraneUK:John wiley and
sons,Ltd.
80. Nelson-Piercy C(2004) Thromboprophylaxis during pregnancy labour and
after vaginnal delivery. RCOG guideline no 37: London RCOG Press.
81. RCOG Green-top guidelines (2010) Malaria in Pregnancy
82. Deep vein thrombosis, diagnosis and treatment and prophylaxis RCOG
guidelines Nov2009.
83. Republic of Sudan, Fedral Ministry of Health Omdurman Maternity
Hospital Guidelines for Dest Practice
84. Murwan Ibrahim Omer and Mohamed Mirghani Salman (eds). Guidelines
for Best Practice. Omdurman Maternity Hospital. Fedral Ministry of
Health. Sudan.
203
85. Mohamed Ahmed A.Elsheikh and Abd Elsalam Gerais(eds).Management
Protocol for Obstetrical and Gynaecological Emergencis. For Safe
Motherhood and low Maternal Mortality Rates. Quality Directorate. Fedral
Ministry of Health Sudan. First edition Jan 2004

204