MSI Guidelines For Obstetric Care v2.0

MSI Guidelines for
Obstetric Care
Lists of acronyms
ACT Artemisinin-based combination therapy LMP Last menstrual period
AMTSL Active management of third stage of labour LMWH Low molecular weight heparin
ANC Antenatal care MCH Mean cell haemoglobin
APH Antepartum haemorrhage MCHC Mean cell haemoglobin concentration
ASB Asymptomatic bacteriuria MCV Mean cell volume
BEmONC Basic emergency obstetric and newborn care MEC Medical eligibility criteria
BP Blood pressure MgSO4 Magnesium sulphate
Bpm Beats per minute MVA Manual vacuum aspiration
BTL Bilateral tubal ligation NICU Neonatal intensive care unit
CBG Capillary blood glucose NS Normal saline
omprehensive emergency obstetric and
CEmONC C OGTT Oral glucose tolerance test
newborn care
OPD Outpatient department
C-S Caesarean section
PID Pelvic inflammatory disease
CTG Cardiotocography
PMTCT Prevention of mother-to-child transmission
D&C Dilatation and curettage
PO per oral
DBP Diastolic blood pressure
PPFP Postpartum family planning
DIC Disseminated intravascular coagulopathy
PPH Postpartum haemorrhage
DIP Diabetes in pregnancy
PPIUD Postpartum intrauterine device
Dpm Drops per minute
PPROM Premature pre-labour rupture of membranes
EDD Expected date of delivery
PROM Pre-labour rupture of membranes
FGM Female genital mutilation
RDT Rapid diagnostic test
FHR Foetal heart rate
RL Ringer’s lactate
FPG Fasting plasma glucose
RPR Rapid plasma reagin test
GA Gestational age
RR Respiration rate
GDM Gestational diabetes mellitus
SBP Systolic blood pressure
Hb Haemoglobin
STI Sexually transmitted infection
ICU Intensive care unit
Ta Temperature
IM Intramuscular
TOT Tetracycline eye ointment
IPTp-SP Intermittent preventive treatment of malaria in
US Ultrasound
pregnancy using sulfadoxine-pyrimethamine
UTI Urinary tract infection
ITN Insecticide-treated bed nets
VBAC Vaginal birth after caesarean section
IUD Intrauterine device
VTE Venous thromboembolism
IUFD Intra-uterine foetal death
IV Intravenous
2
Contents
Introduction 5
Module 1: Antenatal Care
1.0 Introduction 1.2

2.0 Antenatal Contacts 1.3
3.0 Overview of Preventive Measures in ANC 1.10
4.0 Client Education and Counselling 1.14
5.0 Documentation 1.18
6.0 References 1.19
Appendix 1: Birth plan template 1.20
Module 2: Common Pathologies in Pregnancy
1.0 Iron Deficiency Anaemia in Pregnancy 2.2

2.0 Malaria 2.7
3.0 Syphilis 2.15
4.0 Urinary Tract Infections 2.20
5.0 Hypertensive Disorders in Pregnancy 2.23
6.0 Hyperglycaemia in Pregnancy 2.31
7.0 Venous Thromboembolism in Pregnancy 2.45
8.0 References 2.51
Module 3: Intrapartum Care for Normal Labour and Vaginal Delivery
1.0 Stage of Labour 3.2

2.0 Diagnosis of Labour 3.3
3.0 Clinical Care for Each Stage of Labour 3.4
4.0 Analgesia During Labour and Delivery 3.14
5.0 Respectful Maternity Care 3.17
6.0 Summary of Dos and Don’ts During Intrapartum Care 3.19
7.0 References 3.20
Module 4: Obstetric Complications
1.0 Pre-Labour Rupture of Membranes 4.2

2.0 Preterm Labour 4.7
3.0 Late-Term and Post-Term Pregnancies 4.12
4.0 Intrauterine Foetal Death and Stillbirth 4.14
5.0 Prolonged Labour 4.19
© MSI Reproductive Choices 2021
3
6.0 Obstructed Labour 4.23
7.0 Malpositions and Malpresentations 4.27
8.0 Prolapsed Cord 4.34
9.0 Hypertensive Disorders During Labour 4.36
10.0 Vaginal Bleeding in Early Pregnancy 4.37
11.0 Vaginal Bleeding in Late Pregnancy and Labour 4.44
12.0 Postpartum Haemorrhage 4.51
13.0 References 4.58
Module 5: Obstetric Procedures
1.0 Manual Removal of Placenta 5.3

2.0 Manual Uterine Exploration 5.6
3.0 Bimanual Uterine Compression 5.8
4.0 Aorta Compression 5.10
5.0 Intrauterine Balloon Tamponade 5.12
6.0 Episiotomy 5.14
7.0 Repair of Perineal Tears 5.17
8.0 Repair of Cervical Tears 5.23
9.0 Deinfibulation 5.25
10.0 Breech Delivery 5.27
11.0 External Cephalic Version 5.34
12.0 Internal Version and Breech Extraction 5.37
Module 6: Postnatal Care and Postnatal Complications
1.0 The Postnatal Period 6.2

2.0 Recommended Postnatal Care Routine 6.3
3.0 Postnatal Complications 6.7
4.0 Postnatal Contraception 6.15
5.0 References 6.29
Module 7: Newborn Care
1.0 Essential Newborn Care 7.2

2.0 Newborn Resuscitation 7.12
3.0 Care of Sick Newborns 7.18
4.0 Care of Preterm and Low Birth Weight Newborns 7.28
5.0 References 7.32
4
Introduction
The MSI Guidelines for Obstetric Care have been developed to enable
health workers providing obstetric and newborn care with a minimum
set of knowledge and skills. The guidelines are designed to cover the
management of major causes of maternal and newborn morbidity and
mortality, and are meant to be used in CEmONC and BEmONC settings
The present guidelines replace version 1.0. A complete process of revision
and update has been carried out. Most chapters have been completely
rewritten according to the latest international evidence
Most modules include visual job aids such as algorithms and tables that
can be easily printed and used as hard copies or posters in consultations
and labour rooms
This version of the guidelines does not include competency assessment
checklists for obstetric care. Updated obstetric competency assessments
can be found in a separate booklet
The information in this document is considered international best
practice. Programmes may need to adapt it according to their contexts,
whilst following the guidance as closely as possible. Any major deviation
from these guidelines due to differences in national policy or availability of
drugs/devices must be communicated to MDT for approval
5
Module 1
Antenatal Care
Module 1: Antenatal Care
Module contents
1.0 Introduction 1.2
2.0 Antenatal Contacts 1.3

2.1 Schedule of antenatal contacts 1.3
2.2 First antenatal contact 1.4
2.3 Second and subsequent antenatal visits 1.8
3.0 Overview of Preventive Measures in ANC 1.10
4.0 Client Education and Counselling 1.14

4.1 General health advice 1.14
4.2 Birth preparation 1.15
4.3 Birth plan 1.16
4.4 Delivery in BEmONC and CEmONC 1.17
4.5 Individual and group sessions 1.17
5.0 Documentation 1.18
6.0 References 1.19
Appendix 1: Birth plan template 1.20
V1.0 MSI Reproductive Choices Guidelines for Antenatal care 1.1

1.0 Introduction
This module focuses on basic, non-specialised antenatal care. According

to latest international recommendations the 4-visit focused model has been
replaced by the new 2016 WHO model with a recommendation of 8 visits.
Essential interventions are spread throughout the 8 visits
Essential interventions in ANC include:
• Routine prevention of maternal and neonatal tetanus (TT immunisation),
anaemia, malaria in endemic areas (IPTp-SP), vertical HIV transmission,
etc.
• Identification and management of obstetric complications such as
preeclampsia, abnormal presentation, multiple pregnancy, abnormal
bleeding, premature rupture of membranes, etc.
• Identification and management of infections such as syphilis, other STIs
and urinary tract infections
• Planning of a birth plan and promotion of skilled birth attendance,
breastfeeding, early postnatal care, and postpartum contraception
The provision of information and the appropriate support to the

pregnant client are as important as the clinical interventions.
The aim of the antenatal care is to provide a positive pregnancy
experience that allows a positive transition to birth and
motherhood
Depending on the context, clients will not always make 8 visits during ANC.
However, it is strongly recommended to achieve at least a minimum
of 4 visits and adapt the suggested schedule of essential interventions

2.0 Antenatal Contacts
2.1. Schedule of antenatal contacts

• For non-complicated pregnancies, 8 contacts are recommended:
– Visit 1 in the first trimester
– Visits 2 and 3 in the second trimester
– Visits 4-8 in the third trimester
• If the client consults after the second trimester (>26 weeks), at least
4 visits are recommended
• After visit 8, an appointment for delivery at 41 weeks must be given
(see Module 4 for guidance on postterm pregnancy)
Table 1: Antenatal contact schedule

ANC Weeks LMP
Contact 1 12 weeks
Contact 2 20 weeks
Contact 3 26 weeks
Contact 4 30 weeks
Contact 5 34 weeks
Contact 6 36 weeks
Contact 7 38 weeks
Contact 8 40 weeks

2.2. First antenatal contact
2.2.1. Client history
• Past medical history: any surgery or serious illnesses in the past and any
drug allergies
• Current medical history: any ongoing treatments or medical condition
• Family history: any family members suffering from diseases such as
tuberculosis (TB), HIV, high BP, diabetes, or heart disease
• Obstetric history: number of previous pregnancies, complications
(hypertension, haemorrhage, fistulas, etc), miscarriages, stillbirths,
abortions, number of live births and mode of delivery (Caesarean,
instrumental, vaginal birth). Children alive and deceased
• Menstrual history and last menstrual period (LMP)
• Gestational age (GA) calculation
– Calculate the GA in weeks from the LMP to the current day with a
pregnancy wheel or using a calendar
– The calculated LMP needs to be compared to the findings of the physical
examination (uterine size) and/or US findings
– Calculate estimated date of delivery (EDD): add 40 weeks to the first day
of LMP with the calendar/pregnancy wheel or add 9 months plus 7 days
to the LMP
– If the client does not know their LMP, base the gestational age and EDD
on physical exam findings and US
• Social history: family situation and support, detection of any sign of
domestic violence, professional activity, living conditions
• General feeling about the pregnancy, any problems, complaints,
or concerns


2.2.2. Physical examination
• General examination:
– Weight and height
– Blood pressure (while rested and seated)
– Skin, pallor, various veins, oedema, mobility, etc.
• Uterine height:
– First trimester: bimanual examination (at 7 weeks the uterus will
be the size of a chicken egg; at 10 weeks, the size of an orange)
– Second trimester (>13 weeks): fundal height measurement with
measuring tape from upper edge of symphysis pubis to fundus.
The size in cm is approximately equivalent to the weeks of gestation
(+/- 1-2 weeks)
• Foetal wellbeing: see follow up visits
• Genital examination: only if client has complaints or to evaluate female
genital mutilation (FGM)
• Vaginal examination: only if bleeding or other symptoms (e.g. discharge)

2.2.3. Laboratory testing
If any of the below are not tested during ANC, they need to be performed
at delivery
• Blood group: if the client is Rhesus negative and has had previous
pregnancies, ask for previous immunisation or Rhesus disease. Advise
Rh‑immunoglobin postpartum at 28 weeks and/or postpartum depending
on the national protocol
• Urinalysis: test for urinary tract infection (including asymptomatic
bacteriuria), protein and glucose presence. A mid-stream urinary culture
analysis is recommended, but if not available, a midstream onsite gram
stain or a urinary dipstick are advised
• Haemoglobin: haemoglobin (Hb) levels <11 g/dl are considered anaemia.
A full blood count is recommended, but if not available the use of an onsite
hemoglobinometer is advised
• Syphilis:
– Use an on-site treponema-specific rapid test or (if available) a rapid
plasma reagin (RPR) test
– If negative but high risk of infection: retest at third visit (>28 weeks)
– If positive: treat (see Module 2)
• Malaria: perform rapid test in endemic areas (even if asymptomatic)
• HIV: offer HIV test to all clients at their first ANC visit
• Hepatitis B: offer Hepatitis B test to all clients at their first ANC visit

2.2.4. Ultrasound
• A first ultrasound (US) before 20 weeks’ gestational age is recommended,
ideally between 10-14 weeks
• US in the first trimester will provide following information:
– Confirm intrauterine pregnancy, exclude ectopic pregnancy and other
pathologies (molar pregnancy, uterine myomas, ovarian cysts, etc)
– Confirm single or multiple pregnancy (and their typology: di-or mono
amniotic, di or mono chorionic)
– Confirm viability: a foetal heart beat should be visible with embryos
≥ 7 weeks
– Confirm gestational age: only the first US (ideally between 10 and 14
weeks) can confirm or correct the LMP provided by the client. Once
LMP and GA has been confirmed or corrected with the first US (called
“confirmed LMP”), subsequent US will determine if the foetus is growing
accordingly, but the LMP date will not be changed again
• When the first US is done during the first trimester: if there is a
difference of >5 days between LMP/GA and ultrasound, the estimated
date of delivery should be adjusted as per the first trimester ultrasound
• When the first US is done during second trimester: if there is a
difference of >10 days between LMP/GA and ultrasound, the estimated
date of delivery should be adjusted as per the second trimester
ultrasound
• When there has been both a first and second trimester ultrasound,
gestational age should be determined by the earliest ultrasound
• If a higher level of US is available, advise and refer for foetal screening with
Nuchal translucency and other biomarkers between 10 and 14 weeks

2.3. Second and subsequent antenatal visits
At weeks 24-30 and 30-36 (and on admission) the obstetric risk evaluation
form needs to be completed in all MSI obstetric centres
2.3.1. Clients history

• Any complaints, concerns or problems since the last visit
• Presence of foetal movements
2.3.2. Physical exam

• Weight, BP, and fundal height
• Presence of oedema, sings of VTE, colour of conjuctiva or any other
abnormal finding
• Foetal lie and presentation: by external abdominal palpation, identify the
cephalic pole (round, hard and regular) and the pelvic pole (soft, bulkier,
irregular). Palpate and locate the foetal back (hard plane on the laterals of
the uterus in longitudinal presentations) and the foetal limbs
• Foetal heart tones:
– Use a foetal Doppler, or if not available, a Pinard stethoscope
– Place it at the point you have located the foetal back at the shoulder level
Note: Small pelvis or big – Listen for 60 seconds at least, while you take at the same time pulse of
foetuses are not indicative the client to make sure the recorded heart rate is the foetal one (should
of a possible cephalopelvic be always ≥110 bpm)
disproportion (CPD). The
diagnosis of a CPD can only – Routine antenatal cardiotocography is not recommended for pregnant
be confirmed during labour clients to improve maternal and perinatal outcomes
and never during ANC. Do not
• Genital examination: only if complaints or to evaluate FGM or STIs
schedule Caesarean section
based on these findings. • Vaginal examination: only if complaints of contractions, discharge,
or bleeding

If any of the below are not tested during ANC, they need to be performed
at delivery
• Urinalysis: test for urinary tract infection and asymptomatic bacteriuria,
protein and glucose presence
• Haemoglobin: Hb levels <11 g/dl are considered anaemia. Full blood
count testing is the preferred method; if not available, an onsite
haemoglobinometer can be used
• Syphilis: if negative at first ANC visit and high risk of infection, retest at
third visit (>28 weeks)
• Malaria: in endemic areas, perform rapid test at each consultation with
4-week interval (exception: clients who tested positive and were treated
in the 4 weeks prior to the consultation)
• HIV: offer to repeat HIV test in all clients if test was negative in the first
trimester
• Hepatitis B: offer to repeat test in all clients if test was negative in the first
trimester
2.3.4. Ultrasound
• US screening is recommended at around 20 weeks and at 34-36 weeks
(in non-complicated pregnancies)
• US in the second and third trimesters will mainly provide following information:
– Foetal presentation and lie
– Foetal viability
– Foetal growth as compared to confirmed LMP
– Liquor volume (AFI – amniotic fluid index)
– Placental presentation and exclusion/diagnosis of placenta previa
• US by a high-level provider at the third visit (20 weeks) will also provide
a specialised foetal structural assessment to diagnose main foetal
malformations. High-risk clients (e.g. clients with pre-or gestational
diabetes, clients with previous foetal malformations) must always be
offered a high-level structural US

3.0 O
verview of Preventive
Measures in ANC
Table 2: Preventive measures in ANC

The main preventive measures as outlined before are summarised in the
following table. The table can be printed and used as a provider job aid in
prenatal consultations

When to administer/carry out Contact Dosage Observations
1 2 3 4 5 6 7 8
Preventive measures
Iron and folic acid All visits x x x x x x x x 1 tablet/daily = 65 mg Advice on possible gastrointestinal effects (dark faeces,
supplements elemental iron and constipation, heartburn)
400 mcg folate If a combination of iron, folate and other micronutrients is used,
make sure that the amount of elemental iron is between 30-60 mg
(ideally 60 mg)
Tetanus toxoid First and second visit, if no x x 0.5 ml IM A third dose is recommended six months after the second dose
(TT) previous TT vaccine or unknown
immunisation status. TT2 needs Two further doses for clients who are first vaccinated against
to be at least 4 weeks after tetanus during pregnancy should be given after the third dose, in
TT1 and ideally 2 weeks before the two subsequent years or during two subsequent pregnancies
delivery If a client has had 1–4 doses of a TT-CV in the past, they
should receive one dose of a TT-CV during each subsequent
pregnancy to a total of 5 doses
V1.0 MSI Reproductive Choices Guidelines for Antenatal care

Antimalarial During second and third w13 x x x x x 3 tablets single dose Only indicated in high prevalence malaria contexts (P.
(sulfadoxine – trimester when malaria test = sulfadoxine 500 mg falciparum)
pyrimethamine) negative. Aim is to administer + pyrimethamine 25 Ideally the first IPTp-SP should be given as early as with 13
IPTp-SP at least 3 doses of IPTp before mg per tablet weeks. Consider giving the tablets in the first ANC and explain
delivery with one-month interval when to take them
between them
If malaria test positive do NOT administer IPTp but regular
antimalaria treatment
Do not administer in HIV-positive clients under cotrimoxazole
treatment
Anthelmintics Once in 6 months. Not to be x Mebendazole 500 mg In endemic areas of hookworm (prevalence >20%) or high
given in the first trimester once (oral) prevalence of anaemia amongst pregnant clients (>40%)
Albendazole 400 mg
(oral)
1.11
1 2 3 4 5 6 7 8
Preventive measures
Calcium Give to all clients in areas with x x x x x x x Calcium carbonate The intake of calcium needs to be separated from the iron
low dietary calcium intake and to 1.25 g tabs supplement by several hours apart (e.g. morning-afternoon)
clients with high risk of developing (equivalent 500 mg
preeclampsia: obesity, previous elemental Ca) – 1
pre-eclampsia, diabetes, chronic tablet 3 times per day.
hypertension, renal disease, (equivalents to a total
autoimmune disease, nulliparity, dose of 1.5 elemental
advanced maternal age, adolescent calcium daily)
pregnancy and conditions leading
to hyperplacentation and large
placentas (e.g. twin pregnancy).
This is not an exhaustive list but can
be adapted/complemented based

on the local epidemiology of pre-
eclampsia
Start at 20 weeks GA
Aspirin Give to all clients with high risk x x x x x x x x Low-dose
of developing preeclampsia (see acetylsalicylic acid
above) (aspirin) 75mg/day
Start before 20 weeks GA and if
possible, as early as 12 weeks GA
Anti-D If client is Rhesus D negative, give x 1500 IU IM Follow national protocols. In some contexts, only postpartum
immunoglobin as prophylaxis in postpartum anti-D will be indicated for Rhesus-negative mothers and in
others a dose during third trimester or after any potentially
sensitising events (e.g. abortion >9 weeks, second or third
trimester haemorrhage, etc.) will be indicated
Maternal and foetal assessment
History taking All visits x x x x x x x x
and physical
exam
Weight and BP All visits x x x x x x x x

Foetal heartbeat From w18-20 onwards x x x x x x x
Ultrasound At least w12, w20 and w34-36 x x x
1.12
1 2 3 4 5 6 7 8
Maternal and foetal assessment

Iron deficiency All visits x x x Ideally the testing should be done with a full blood count. In
anaemia testing case of not having it available, an onsite testing of Hb with
haemoglobinometer is advised
Urine analysis At least at w12, w26, w34 x x x Detection of proteins, nitrites, leucocytes and glucose. Any
abnormality needs to be managed accordingly (see Module 4)
Ideally the testing should be done with mid-stream urinary
culture. If not available, an onsite gram-stain or urine dipstick are
advised
Syphilis w12 (first visit). If negative and x
high risk offer again in third
trimester
HIV w12 (first visit) and offer again in x

third trimester if negative
Hepatitis B w12 (first visit) and offer again in x If the mother tests positive: refer to specialised care (hepatology)
third trimester if negative if available. No specific obstetric measures are needed during
delivery besides usual PPE and care of staff for potential needle
stick injuries
For the neonate: routine hepatitis vaccination within 24 hours
after birth (demonstrated to prevent 70 to 95% of neonatal
infections)
Health All visits x x x x x x x x
promotion,
support and
counselling
1.13
4.0 C
lient Education
and Counselling
Client education and counselling is as important as any medical interventions.

The main objectives are:
• Provide health advice (including postpartum contraception) to prevent maternal
and neonatal morbi-mortality
• Develop a birth plan to allow clients to actively participate in the planning of
their labour and delivery
• Support the transition from pregnancy to birth and motherhood providing a
positive pregnancy experience
4.1. General health advice

• Healthy diet, rich in iron, calcium, and vitamin D to help protect against
anaemia and pre-eclampsia
• Avoidance of any substance, tobacco, or alcohol use
• Prevention of malaria by using an insecticide treated bed net
• Advice (and detection) of intimate partner violence, FGM or other specific
circumstances in the client’s life
• Sex education to help minimise the risk of STIs and HIV. ANC is an opportunity
to encourage voluntary HIV counselling / testing
• Family planning: ANC visits provide a golden opportunity to discuss birth
spacing and postpartum methods of contraception

4.2. Birth preparation
Since most of the obstetric complications cannot be predicted, every pregnancy
needs preparation for a possible emergency. The following points need to be
discussed with all pregnant clients and their families/partners
Table 3: Birth preparation
Danger signs In presence of any of these signs, a pregnant client should go to the nearest health
facility without delay:
• High fever with/without abdominal pain or the client is too weak to get out of bed
(indicating infection/sepsis)
• Fast or difficult breathing
• Decreased or absent foetal movements
• Any bleeding during pregnancy or heavy bleeding after the baby is born (> 500 ml)
• Continuous severe abdominal pains (with no rest between them)
• Severe headache with blurred vision
• Convulsions or loss of consciousness
• Labour lasting more than 12 hours
• Placenta takes more than 30 minutes to deliver
• Fluids leaking without labour starting (PROM)
Signs of labour ny of the following signs of labour require the client to seek care in the selected
A
health facility for birth. Make sure the client and family know confirmed LMP and
EDD:
• Regular contractions (3 contractions in 10 min of about 40 sec) for 1 hour
• Any leakage of fluid (PROM)
What to expect during labour, delivery • Explain how the delivery will take place. If possible, allow the client to visit the health
and postpartum facility to see labour, delivery and postpartum facilities
• Explain pain management options during labour and delivery
• Explain vaginal delivery, instrumental and C-S deliveries
• Explain normal postpartum (including pain, discomfort, etc) and breastfeeding
• Counsel on contraceptive options after delivery
• Explain what the client should bring for the admission (baby clothes, pads, soap,
money, food, etc)
• Encourage to start organising for appropriate support for postpartum
Support the choice of health facility Support the choice of health facility by:
• Explaining options of BEmONC and CEmONC (revise if the patient needs to deliver
in a CEmONC) as well as neonatal care levels and referral possibilities
• Inform about location of higher-level facilities/referral centres
• Provide contact information for emergencies
• Explain how the health facility works (visiting hours, staff presence, etc.)
Blood donation Ask to locate 2-3 voluntary donors for blood in case of need
Transport and logistical arrangements Encourage the client and family to have a 24/7 possibility of transport to the facility
in case of emergency/need. This includes financial arrangements, domestic
arrangements, etc.

4.3. Birth plan
A birth plan expresses the preferences and desires of the client for their delivery
and postpartum period at the facility and needs to be respected as far as the
health of the client or new-born is not compromised by these preferences
Record the birth plan (signed by the client and the midwife) with at least the
following information:
• Choice of a skilled attendant and facility to deliver
• A transport plan to get to the facility
• Choice of birth companion and level of presence in case of normal,
instrumental, or C-S delivery
• Preferences for pain management, birth position, breastfeeding, etc.
Please refer to Appendix 1 for a complete template of birth plan

4.4. Delivery in BEmONC and CEmONC
The following table summarises the conditions under which a client should be
managed in a CEmONC facility
Table 5: Absolute indications for a CEmONC delivery
Management in a CEmONC (absolute indications)

• History of uterine rupture
• History of Caesarean section
• History of any uterine scar (e.g. myomectomy)
• History of vesico-vaginal or recto-vaginal fistula
• History of third- or fourth-degree tear
• History of symphysiotomy
• History of abruptio placentae, severe pre-eclampsia or eclampsia in previous
pregnancy
• Transverse lie
• Breech presentation, especially in primiparas
• Pre-eclampsia or eclampsia
• Gestational diabetes or diabetes in pregnancy
• Bleeding after first trimester
• Any antepartum or intrapartum bleeding
• Severe anaemia (Hb < 7 g/dl)
• Multiple pregnancy
• Preterm labour and PPROM
• Any pregnant clients under LMWH prophylaxis for VTE risk
4.5. Individual and group sessions

• It is advisable to complement the individual counselling performed during
consultation with group sessions
• Groups of 10-15 pregnant clients and one midwife can be organised in which
clients can exchange their experiences and reinforce the health messages
provided during consultations

5.0 Documentation
• Clinical documents are a legal record of what happened to the client whilst in
Please remember: the provider’s care. They are a cornerstone to facilitate continuum of care to
a client as well as to assure client safety and clinical accountability
What is not documented is
“not done” • All findings need to be documented including history and physical
examination findings, test results, medications, and the signed birth plan
• Depending on each context, clients may keep hold of their own records or
they will be kept in the facility (or both options by having electronic copies)

6.0 References
• WHO recommendations on antenatal care for a positive pregnancy

experience. Geneva: World Health Organization; 2016.
•P
regnancy, Childbirth, Postpartum and Newborn Care A Guide for
Essential Practice-3rd ed. Geneva. World Health Organization; 2016.
• Essential Obstetrics and Newborn care. (2019) Medicines Sans Frontiers.
• WHO recommendations for prevention and treatment of pre-eclampsia
and eclampsia. [Internet]. 2011 [cited 2020 Jun 30]. Available from: http://
whqlibdoc.who.int/publications/2011/9789241548335_eng.pdf
• WHO recommendations: drug treatment for severe hypertension in
pregnancy [Internet]. Geneva: World Health Organization; 2018 [cited 2020
Sep 17]. Available from: https://www.ncbi.nlm.nih.gov/books/NBK535778/
• Nutritional anaemias: tools for effective prevention and control. Geneva:
World Health Organization; 2017.
• WHO Managing complications in pregnancy and childbirth A guide for
midwives and doctors, 2007 (Reprint)
• Life Saving Skills Manual Essential Obstetric Care. Royal College of
Obstetricians and Gynaecologists (2006) (In partnership with Liverpool
School of Tropical Medicine, WHO, Liverpool Associates in Tropical Health
LATH)
• Oxford Handbook of Midwifery (2011 2nd edition). Medforth (et al) Oxford:
Oxford University Press
• Hepatitis B. Epidemiology and Prevention of Vaccine-Preventable
Diseases. The Pink Book. http://www.cdc.gov/vaccines/pubs/pinkbook/
hepb.html#hepA
• NHS. How to make a birth plan [Internet]. Available from: https://www.nhs.
uk/conditions/pregnancy-and-baby/how-to-make-birth-plan/

Appendix 1:
Birth plan template
MY BIRTH PLAN
Name
............................................................................................................................................................................................................
Due date
............................................................................................................................................................................................................
Where to give birth

You will have a choice about where to have your baby. Your midwife or doctor will be able to tell you what services
are available locally and advise you on any issues to do with your health or pregnancy that may affect your choice.
I would like to give birth at home
I would like to give birth in a midwifery unit (BEmONC)
I would like to give birth in a maternity team unit in hospital (CEmONC)
I am not sure yet where I would like to give birth
My comments on where I would like to give birth and why:
............................................................................................................................................................................................................
............................................................................................................................................................................................................
............................................................................................................................................................................................................
Plan of transport
In case of labour start or any other emergency related to your pregnancy, you need to have identified one or several)
modes of transport that are available 24/7. This involves not only the vehicle needed and its availability, but also any
financial and logistic arrangements needed (e.g. who will stay at home in case there are children to take for)
I have identified and arranged a 24/7 transport plan
I have not yet identified and arranged a 24/7 transport plan
My comments on my transport plan:
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Companions
Having a companion you can depend on and who can support you during your labour can be helpful.
It has been shown to reduce the need for pain relief.
I would like my partner or companion(s) to be with me during labour
I would not like my partner or companion(s) to be with me during labour
I am not sure yet whether I would like my partner or companion(s) to be with me
My birth partner or companion is:
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Companions during a vacuum delivery

A vacuum delivery, sometimes called ventouse, is when the baby is guided out by suction using a cap fitted to its head
I would like my partner or companion(s) to be with me if I have a forceps or vacuum delivery
I would not like my partner or companion(s) to be with me if I have a forceps or vacuum delivery
I do not mind if my partner or companion(s) is with me if I have a forceps or vacuum delivery
I am not sure yet whether I would like my partner or companion(s) to be with me if I have a forceps or vacuum
delivery
Companions during a Caesarean section

A Caesarean section is when the baby is delivered by cutting through the abdomen and into the womb. This will only
be performed when it is necessary, but there are situations where this is the safest option for either you or your baby.
If your Caesarean section is carried out under local anaesthetic and you are awake, your partner or companion may
sit with you.
I would like my partner or companion to be with me if I have a Caesarean section
I would not like my partner or companion to be with me if I have a Caesarean section
I do not mind if my partner or companion is with me if I have a Caesarean section
I am not sure yet if I would like my partner or companion to be with me if I have a Caesarean section
Birthing equipment
You may find that items such as wall bars, mats or beanbags help you to change position and remain comfortable
during labour. If you’re giving birth in a maternity unit, your midwife will be able to tell you if specific items are
normally available. However, you may need or prefer to provide some equipment yourself.
I plan to use equipment such as mats or beanbags during labour
I do not plan to use equipment such as mats or beanbags during labour
I am not sure yet whether I would like to use equipment such as mats or beanbags during labour
My comments on birthing equipment and whether I will provide it:
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Any other comments or preferences on birth location, facilities or companions:

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Monitoring during labour

Every baby is monitored throughout labour to make sure that it is not in distress. There are different ways of
monitoring the baby’s heartbeat.
I have discussed with my midwife how I would like my baby’s heart to be monitored if everything is straightforward
I have not discussed with my midwife how I would like my baby’s heart to be monitored if everything is
straightforward
My comments on monitoring my baby during labour:
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Keeping active during labour

Keep active for as long as you feel comfortable. This helps the progress of the birth. Keeping active doesn’t mean
doing anything strenuous, just moving around normally.
I would like to move around during labour
I would not like to move around during labour
I do not mind whether or not I move around during labour
I am not sure yet whether I would like to move around during labour
My comments on moving around during labour:
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Positions for labour and birth

Find the positions you prefer and which will make labour easier for you. Try out various positions at antenatal class or
at home to find out which are the most comfortable for you. You can choose as many positions as you want and vary
them throughout your labour.
I would like to be in bed with my back propped up by pillows
I would like to be standing
I would like to be sitting
I would like to be kneeling
I would like to be kneeling on all fours
I would like to be squatting
I would like to be lying on my side
I am not sure yet which positions I would like to be in during labour
Skin-to-skin contact with your baby

After the birth you can have your baby lifted straight onto you before the cord is cut so that you can be close to each
other immediately. If you prefer, you can ask the midwife to wipe your baby and wrap him or her in a blanket first.
I would like my baby delivered straight onto my tummy
I would like my baby cleaned first before being given to me
I do not mind if my baby is cleaned before being given to me
I am not sure yet whether I would like my baby delivered straight onto my tummy
My comments on anything special I would like to happen immediately after the birth:
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Midwives, nurses and doctors in training

Midwives, nurses and doctors need to observe clients in labour as part of their training. They will always be
supervised by a senior health professional.
M
y midwife and I have discussed my thoughts about having midwives, nurses or doctors in training with me
during labour
M
y midwife and I have not discussed my thoughts about having midwives, nurses or doctors in training with me
during labour
Other comments or preferences about my labour and birth:
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Pain relief options
There are many different pain relief options. Some clients use a combination of methods. You may find that you want
more pain relief than you had planned, or that more effective pain relief may be advised to assist with delivery. You
can use a number of different methods at different times.
I would like to try breathing and relaxation
I would like to try massage
I would like to try pain-relieving injections
I would like to try a spinal anaesthesia (if available)
I would like to try other methods of pain relief
I would like to try to manage without pain relief
My preferences for pain relief:
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Having an episiotomy
An episiotomy is a cut in the perineum (the area between the vagina and anus). This may be necessary if the
perineum won’t stretch enough and may tear, or if the baby is short of oxygen and needs to be delivered quickly.
I have discussed with my midwife or doctor why an episiotomy might be necessary
I have not discussed with my midwife or doctor why an episiotomy might be necessary
My feelings about the possible need for an episiotomy:
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Delivering the placenta after the birth

After your baby is born your midwife will offer you an injection in your thigh. This contains the drug syntometrine or
syntocinon which helps the womb contract and can prevent the heavy bleeding that some clients may experience
without it.
I have discussed with my midwife what happens after labour when the placenta is delivered
I have not discussed with my midwife what happens after labour when the placenta is delivered
My preferences about delivering the placenta:
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Feeding your baby
Breast milk is the best form of nutrition for babies as it provides all the nutrients a baby needs and has lasting
benefits for the health of your child. Infant formula milk can be used as an alternative to breast milk.
I would like to breastfeed my baby
I would like to bottle feed my baby
I would like to try a mixture of breastfeeding and bottle feeding
I am not sure yet how I would like to feed my baby
My comments about feeding my baby:
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Vitamin K for your baby

Vitamin K is needed to make the blood clot properly. Some newborn babies have too little vitamin K so it may be
suggested that your baby be given vitamin K either by injection or by mouth.
I have given my midwife my consent to give my baby vitamin K
I have not given my midwife my consent to give my baby vitamin K
Any other comments or preferences about me and my baby immediately after the birth:
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Postpartum contraception
Your midwife/doctor will inform you about healthy birth spacing and the options and methods available to you if you
wish postpartum contraception
I would like to have postpartum contraception
I would not like to have postpartum contraception
I have not yet decided about postpartum contraception
What is the contraceptive method you have chosen and any additional comments
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Special requirements
Please tick any that apply to you. You can fill in more details in the box below.
I need an interpreter who speaks the same language as me
I need a sign language interpreter
I have special dietary requirements
I and/or my partner have special needs
I would like certain religious customs to be observed
More information about my special requirements:
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Name, date and signature of health worker with whom the birth plan has been made:
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Name, date and signature of the client:
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Module 21
AntenatalPathologies
Common Care
in Pregnancy
Module 2: Common Pathologies
in Pregnancy
Module contents
1.0 Iron Deficiency Anaemia in Pregnancy 2.2 5.0 Hypertensive Disorders in Pregnancy 2.23
1.1. Definition 2.2 5.1. Definition 2.23
1.2. Risks/complications 2.2 5.2. Classification and clinical presentation 2.24
1.3. Diagnosis 2.2 5.3. Prevention of hypertensive disorders in 2.25
1.4. Prevention 2.3 pregnancy (see Module 1)
1.5. Management 2.3 5.4. Treatment 2.26
2.0 Malaria 2.7 6.0 Hyperglycaemia in Pregnancy 2.31

2.1. Background information 2.7 6.1. Definitions 2.31
2.2. Risks/complications 2.7 6.2. Introduction 2.32
2.3. Clinical presentation 2.8 6.3. Risks/complications 2.33
2.4. Diagnosis 2.8 6.4. Diagnosis 2.34
2.5. Prevention 2.9 6.5. Management during antenatal care 2.37
2.6. Treatment 2.10 6.6. Management during delivery 2.42
6.7. Management during postpartum period 2.44
3.0 Syphilis 2.15
3.1. Background information 2.15 7.0 Venous Thromboembolism in Pregnancy 2.45
3.2. Clinical presentation 2.15 7.1. Definition 2.45
3.3. Diagnosis 2.16 7.2. Risk factors 2.45
3.4. Risks/complications 2.17 7.3. Diagnosis 2.47
3.5. Prevention 2.17 7.4. Prophylaxis 2.48
3.6. Treatment 2.18 7.5. Management of clients under LMWH 2.50
prophylaxis
4.0 Urinary Tract Infections 2.20
8.0 References 2.51
4.1. Asymptomatic bacteriuria (ASB) 2.20
4.2. Cystitis 2.21
4.3. Pyelonephritis 2.22
1.0 Iron Deficiency Anaemia
in Pregnancy
1.1. Definition
Anaemia in pregnancy is defined as a condition in which the haemoglobin
level in a pregnant client is less than 11 g/dl. A pre-existing anaemia can be
aggravated by pregnancy
Anaemia in pregnancy can be classified as follows:
• Mild anaemia: 9 g/dl– 10.9 g/dl
• Moderate anaemia: 7 g/dl – 8.9 g/dl
• Severe anaemia: <7g/dl
1.2. Risks/complications
Anaemia during pregnancy can contribute to:
• Preterm birth
• Low birth weight
• Puerperal sepsis
• PPH: anaemia during pregnancy will aggravate the impact of a PPH
1.3 Diagnosis
Clinical history and examination
Frequent signs and symptoms are pallor, weakness, headache,
palpitations, dizziness, dyspnoea, poor concentration, and irritability
Investigations
• Full blood count: low Hb (<11 g/dl), low mean cell volume (MCV),
mean cell haemoglobin (MCH), and low mean cell haemoglobin
concentration (MCHC)
• If no full blood count available: check Hb with an onsite
hemoglobinometer

• Additional investigations are advisable to rule out any other cause
of anaemia:
– Peripheral blood film: confirm signs of iron deficiency, rule out malaria
or sickle cell anaemia
– Urine analysis and urine microscopy: rule out schistosomiasis
– Stool sample: rule out schistosomiasis and other parasites (helminths)
– Sickling test: rule out sickle cell anaemia (especially in countries with
high prevalence)
An Hb <11/dl with a standard hemoglobinometer (when no other tests are
available) is enough to put the client under iron-folate supplements
1.4. Prevention
• Nutritional advice should be given to all pregnant clients focusing on
locally available and affordable iron-rich foods (red meat, poultry,
legumes, nuts and seeds, etc.)
• Provide deworming with anthelminthics (see Module 1) in endemic
contexts
• Give intermittent preventive treatment for malaria where indicated
(see Module 1)
• Provide routine supplementation with folic acid/ferrous salts (e.g. ferrous
sulphate or ferrous fumarate) during pregnancy and postpartum period to
all clients (even those with Hb>11 g/dl)
1.5. Management
• Choice of treatment should be guided by duration of pregnancy, severity
of anaemia and presence of complications. The following flowcharts detail
the management of mild, moderate and severe anaemia depending on
gestational age and labour occurrence
• Severe anaemia should be managed by a doctor and referred for delivery
in a CEmONC

Figure 1. Management of iron-deficiency anaemia in pregnant clients < 36 weeks
Iron deficiency anaemia in pregnant clients < 36 weeks
Hb=9-10.9 g/dl Hb=7-8.9 g/dl Hb=5-6.9 g/dl Hb<5 g/dl
1-2 tablets of iron-folate 2 tabs of iron-folate daily Admission and

(65mg/400mg) daily transfusion of
Well tolerated Any of the following: whole blood or

decompensation signs, packed cells
Follow up in 2-4 weeks severe malaria or any
Follow up according kind of infection, sickle
3 tabs of iron folate daily
to ANC schedule (see cell or heart disease
Module 1) 2 tabs iron /folate
Administer preventive
treatment for malaria, on discharge
Follow up in 2 weeks
Administer preventive helminthiasis according to Admission and
treatment for malaria, protocol (see Module 1) transfusion of whole
helminthiasis (see blood or packed cells Follow up in
Module 1) Preventive treatments 2 weeks
Talk about birth plan and as per protocol
strongly advice delivery in
facility, ideally CEmONC
Talk about birth plan and Preventive
Delivery needs to take
advise delivery in facility treatments as
place in CEmONC
per protocol
Delivery needs
to take place in
CEmONC
2.4
Figure 2. Management of iron-deficiency anaemia in pregnant clients ≥ 36 weeks
Iron deficiency anaemia in pregnant clients ≥ 36 weeks
Hb=9-10.9 g/dl Hb=7-8.9 g/dl Hb=6-6.9 g/dl Hb<6 g/dl
1-2 tablets of iron-folate 2 tabs of iron-folate daily Admission and

(65mg/400mg) daily transfusion of
Well tolerated Any of the following: whole blood or
decompensation packed cells
Follow up in 2 weeks signs, severe malaria

Follow up according or any other infection,
3 tabs of iron folate daily
to ANC schedule (see sickle cell or heart
Module 1) disease 2 tabs iron-folate
Administer preventive
treatments as per daily on discharge
Administer preventive protocol Admission and
treatment for malaria, transfusion of whole
helminthiasis according to blood or packed Follow up in
protocol (see Module 1) Talk about birth plan and Preventive treatments cells 2 weeks
strongly advice delivery as per protocol
in CEmONC
2 tabs iron-folate on
Talk about birth plan and discharge Preventive
Delivery in CEmONC
advice delivery in facility treatments as per
(BEmONC or CEmONC) protocol
Preventive
treatments as per Delivery in
protocol CEmONC
Delivery in CEmONC
2.5
Figure 3. Management of iron-deficiency anaemia in pregnant clients in labour
Iron deficiency anaemia in pregnant clients in labour
Hb=9-10.9 gr/dl Hb=7-8.9 gr/dl Hb<7 gr/dl
Postpartum discharge on Blood grouping, cross

iron-folate for at least 3 match and ensure Transfusion

months (1-2 tabs daily) availability of blood/donors
Delivery may need

Check Hb during oxygen support and/
postpartum admission or assisted vaginal
delivery to shorten
second stage of labour
Note: Active management in
third stage of labour should be Discharge on iron-folate
routine for all deliveries, but in for at least 3 months Check Hb during
anaemic clients extra caution (2 tabs daily) postpartum admission
must be placed to diagnose
early PPH. Additionally, any
tears or lacerations must be
promptly sutured to avoid
further blood loss Discharge on iron-folate
for at least 3 months
2.6
2.0 Malaria
2.1. Background information

• Malaria is a parasitic infection caused by 5 species of plasmodium:
P. falciparum, P. vivax, P. ovale, P. malariae and P. knowlesi
• Uncomplicated malaria can be caused by all type of plasmodium,
severe malaria is commonly caused by P. falciparum and less frequently
by P. vivax or P. ovale
• Uncomplicated malaria can rapidly progress to severe malaria especially
in pregnant clients, and therefore needs to be treated without delay
Malaria should be considered the most likely diagnosis in a pregnant client
with fever who has been in a malaria endemic area
• Stillbirths
• Abortions
• Anaemia
• Increased risk of maternal and neonatal mortality

2.3. Clinical presentation
2.3.1. Uncomplicated malaria
Fever, chills, sweating, headache, malaise, joint and muscle pain, nausea,
vomiting and anorexia. Anaemia is a frequent presentation in pregnant
clients
2.3.2. Severe malaria

In addition to the above, one or more of the following:
• Seizures within the last 24 hours
• Extreme weakness and /or impaired consciousness
• Respiratory distress
• Shock
• Jaundice
• Haemoglobinuria (dark red urine)
• Signs of acute renal failure (oliguria)
• Abnormal bleeding (blood in stools, petechiae, etc.)
Severe malaria needs immediate admission and IV treatment
2.4. Diagnosis
2.4.1. Rapid diagnostic tests (RDTs)
• Rapid antigen detection tests can provide a result onsite within minutes
with a drop of blood
• They may remain positive after treatment for up to 3 weeks

2.4.2. Microscopy
• Parasite detection and quantification of parasitaemia through a thin or
thick film
• Requires an experienced laboratory technician and laboratory facilities
• May give negative result if parasitized erythrocytes are sequestrated in
capillaries or placental vessels
2.4.3. Additional tests (recommended for all patients with

severe malaria)
• Haemoglobin for the monitoring of anaemia
• Blood glucose level for the detection of hypoglycaemia
• Note: If no diagnostic tests are available, the clinical suspicion of malaria

is enough to start treatment
Severe malaria is frequently misdiagnosed as eclampsia. If malaria

cannot be excluded start treatment for both conditions until one of them
can be ruled out (start ACT and MgSO4)
2.5. Prevention
It is important to counsel the client on ITN and administer IPTp-SP as per
ANC protocol (see Module 1)

2.6. Treatment
Below treatments are internationally approved regimes. However, it is
possible that there will be national protocols with noticeable differences
(e.g. use of quinine in first trimester pregnancies)
2.6.1. Uncomplicated malaria

Arthemisin-based combined treatments (ACT) are recommended in all
trimesters of pregnancy with a duration of 3 days
Table 1. Oral ACT regimes for uncomplicated malaria in pregnant clients
Artemether (80 mg) PLUS lumefantrine (480 mg) Twice daily for three days
Artesunate (200 mg) PLUS amodiaquine (540 mg) Once daily for three days
Artesunate (200 mg) PLUS mefloquine (440 mg) Once daily for three days
Dihydroartemisinin (160 mg) PLUS piperaquine Once daily for three days
(1280 mg)
Artesunate (200 mg) PLUS sulfadoxine/ Artesunate (200 mg) once

pyrimethamine (1500/75 mg) daily for three days PLUS
sulfadoxine/pyrimethamine
(1500/75 mg) single dose
only on day one
• In case of fever give paracetamol 1 g oral every 6-8 hours

• Encourage adequate oral fluids

Notes:
• Only when ACTs are not available:
Quinine salt (dihydrochloride or Quinine salt (dihydrochloride or sulphate)

sulphate) PLUS clindamycin 300 mg 10 mg/kg body weight by mouth every
8 hours PLUS clindamycin 300 mg every
6 hours for seven days
• Primaquine is contraindicated in pregnant clients and mothers who are

breastfeeding an infant less than six months of age
• When administering ACT regimen after severe malaria: do not give
artesunate/mefloquine to clients that had neurological signs during severe
malaria status (convulsions)
2.6.2. Severe malaria

Severe malaria needs admission into a high intensity care unit with hourly
monitoring of vital signs and urine output as well as appropriate fluid
management
2.6.2.1 Antimalarial drugs

Notes for all the below options:
• Continue the parental (IM or IV) mantainance dosing until the client is
conscious and able to tolerate oral medication or for at least 24 hours.
Then give full course of oral ACT
• Do not give artesunate/mefloquine if the patient had seizures
• Monitor blood glucose levels for hypoglycaemia every 4 hours in any
clients with severe malaria and on hourly basis if the patient is on
quinine IV

Table 2. Parental regimes for severe malaria in pregnant client
ARTESUNATE (IV OR IM) TREATMENT OF CHOICE FOR SEVERE MALARIA IN ALL TRIMESTERS
• Begin treatment with IV or IM route for at least 24 hours and until the client can tolerate oral
medications. Then give a complete oral treatment with ACT for three days (see uncomplicated
malaria)
• IV route is preferred (slow IV push over 1-2 min), if not possible IM to anterior thigh
• IV and IM routes have different dilutions: 10 mg/ml for IV route, 20 mg/ml for IM route
• Loading dose: Artesunate 2.4 mg/kg body weight IV every 12 hours for at least 24 hours
(3 doses: on admission-12h-24h)
• Maintenance dose: Artesunate 2.4 mg/kg body weight IV as a single bolus once daily
beginning on the second day of treatment. Continue the maintenance dosing schedule until the
client is conscious and able to swallow; then give a complete 3-day oral treatment with ACT
• Monitor blood sugar every 4 hours
• If artesunate is not available, give intramuscular artemether (see below)
ARTHEMETER IM Second choice after artesunate
• Loading dose: Artemether 3.2 mg/kg body weight IM as a single dose on the first day of
treatment (D1)
• Maintenance dose: Artemether 1.6 mg/kg body weight IM once daily beginning on the second
day of treatment (D2). Continue the maintenance dosing schedule until the woman is conscious
and able to tolerate oral medications; then give a complete 3-day oral regimen of ACT
• Monitor blood sugar every 4 hours
• If artemether is unavailable, IV quinine should be started immediately and continued until
artemether is obtained
QUININE • Loading dose: Quinine dihydrochloride 20 mg/kg body weight in IV fluids (5% dextrose 500
DIHYDROCHLORIDE IV ml) over four hours
– The next 4 hours: administer a plain 5% glucose 500 ml drip
– Never give an IV bolus injection of quinine
– If it is known and confirmed that the client has taken an adequate dose of quinine (1.2 g)
within the preceding 12 hours, do not give the loading dose. Proceed with the maintenance
dose (see below)
– If the history of treatment is not known or is unclear, give the loading dose of quinine
– Wait four hours (eight hours from the start of the first dose) before giving the maintenance
dose
• Maintenance dose: Quinine dihydrochloride 10 mg/kg body weight over four hours
– Repeat every eight hours from the start of the last dose (i.e. quinine infusion for four hours,
no quinine for four hours, quinine infusion for four hours, etc.)
• Monitor blood sugar every hour

Convulsions
• Maintain airway (place Goeddel airway if possible), place patient on their
side and give diazepam 10 mg IV slowly over two minutes
• If eclampsia is diagnosed in addition to malaria, prevent subsequent
convulsions with magnesium sulphate
• If eclampsia is excluded, prevent subsequent convulsions with phenytoin
– Phenytoin loading dose: Infuse phenytoin 1 g (approximately 18 mg/
kg body weight) in 50–100 mL normal saline over 30 minutes (final
concentration not to exceed 10 mg per mL)
– Flush IV line with normal saline before and after infusing phenytoin
– Only normal saline can be used to infuse phenytoin. All other IV fluids
will cause crystallization of phenytoin
– D
o not infuse phenytoin at a rate exceeding 50 mg per minute due
to the risks of irregular heartbeat, hypotension, and respiratory
depression
– Complete administration within one hour of preparation
– Maintenance dose: Give phenytoin 100 mg IV slowly over two minutes
or by mouth every eight hours beginning at least 12 hours after the
loading dose

Fluid balance
• Maintain a strict fluid balance chart and monitor the amount of fluids
administered and urine output to ensure that there is no fluid overload.
Clients with severe malaria are prone to fluid overload
• If pulmonary oedema develops:
– Prop up the client
– Oxygen at 4 L per minute by mask or nasal cannula
– Furosemide 40 mg IV as a single dose
– If urine output is poor (less than 30 mL per hour): measure serum
creatinine; and rehydrate with IV fluids (normal saline, Ringer’s
lactate)
– If urine output does not improve, give a second single dose of
furosemide 40 mg IV and continue to monitor urine output
– If urine output is still poor (less than 30 mL per hour over four hours)
and the serum creatinine is more than 2.9 mg/dL, refer the client to a
tertiary care centre for management of renal failure
Hypoglycaemia
• Hypoglycaemia in severe malaria is common, can occur without
apparent symptoms and at any time during the illness, especially after
initiation of quinine therapy
• Monitor blood glucose levels using a stick test every four hours
• If the client is receiving quinine IV, monitor blood glucose levels every
hour
• If hypoglycaemia is detected, give 50% dextrose 50 mL IV followed by
dextrose (5% or 10%) 500 mL infused over eight hours
• Monitor blood glucose levels and adjust infusion accordingly
• Monitor fluid balance carefully

3.0 Syphilis
3.1. Background information

Syphilis is a sexually transmitted infection caused by the bacterium
Treponema pallidum. It can also be passed from mother to foetus
(congenital syphilis)
The clinical presentation is very variable and depends on the time passed
since the infection. It is not infrequent that syphilis passes undetected until
tested
3.2. Clinical presentation

3.2.1. Pregnant clients
• Early syphilis/primary syphilis: 2-3 weeks after infection
– Small painless genital sore or ulcer (but can also appear on buttocks,
fingers, lips) with or without enlarged lymph nodes
– The sore disappears spontaneously after 2-8 weeks
• Secondary syphilis (weeks after primary)
– Rash on palms, soles of feet
– Similar growths as genital wards on vulva
– White patches in the mouth
– Flu-like symptoms
– Sometimes swollen glands, hair loss
– Symptoms disappear spontaneously after some weeks
• Tertiary syphilis/latent syphilis (can appear years later)
– Neurological complications such as meningitis, dementia, stroke,
vision problems, etc.
– Heart problems

3.2.2 Neonate with congenital syphilis
• Red rash, grey patches, blisters or peeling skin on palms of hands and
soles of feet
• “Snuffles”: highly infectious rhinitis with nasal obstruction
• Abdominal distension due to enlarged liver and/or spleen
• Jaundice
• Pallor, anaemia
• Generalised oedema
• Anal condylomas
• Paralysis of one limb
• Spirochetes seen on dark field examination of lesion, body fluid or
cerebrospinal fluid
• Some very low birth weight infants with syphilis have signs of severe
sepsis with lethargy, respiratory distress, skin petechiae or other bleeding
3.3. Diagnosis
If a client has not been screened for syphilis during ANC, a syphilis test
needs to be performed at delivery or early postpartum period
• On-site rapid treponema-specific syphilis test or
• Rapid plasma reagin (RPR) test

• IUFD and stillbirth
• Prematurity
• Neonatal mortality
• Congenital syphilis
3.5. Prevention
• All pregnant clients and their partners should be screened and, where
indicated, treated for syphilis at the first antenatal visit, preferably before
16 weeks gestation, and again in late pregnancy if negative result and
high-risk client or context of high prevalence of syphilis
• If a pregnant client was not tested during pregnancy a test for syphilis
must be done during labour or the immediate postpartum period, before
they are discharged

3.6. Treatment
3.6.1. For the mother
Table 3. Syphilis treatment for pregnant clients
Early syphilis (primary, secondary, or Benzathine benzylpenicillin IM: 2.4 IU

latent infection < 2 years) (1.8 g) single dose (1.2 IU in each buttock
side)
Late latent syphilis (>2 years infection Benzathine benzylpenicillin IM: 2.4 IU
or unknown duration) (1.2 IU in each buttock side) once per
week for 3 weeks
For clients allergic to penicillin • Erythromycin 500 mg orally four times
daily for 14 days in early and for 30
days in late syphilis OR
• Azithromycin 2 g stat dose orally only
for early syphilis OR
• Ceftriaxone 1 g im once daily for 10
days ONLY for early syphilis
• None of these regimes are proven to
effectively treat syphilis and prevent
congenital syphilis. Erythromycin and
azithromycin do not cross the placenta,
and thus may treat maternal infection
but do not prevent congenital syphilis.
(see neonatal treatment below)
Administer the same treatment to the client’s sexual partner(s)

3.6.2. For the neonate
Table 4. Syphilis treatment for the neonate
Mother has positive syphilis test at Benzathine benzylpenicillin IM: 50 000

any time in pregnancy or intrapartum IU/kg body weight single dose
(regardless if she was treated or not)
AND neonate has no clinical signs of
syphilis
Mother did not receive adequate HOSPITALISE/REFER THE NEONATE
treatment OR neonate has clinical TO ASSURE FULL COURSE OF
signs of syphilis TREATMENT
Benzylpenicillin IV:
First 7 days (D1-D7): 50 000 IU/kg every
12 hours (100 000 IU/kg daily)
3 more days (D 8 to D10): 50 000 IU/kg
every 8 hours
OR
Procaine benzylpenicillin IM (second

choice due to IM route):
D1 to D10: 50 mg/kg (50 000 IU/kg)
single IM dose every 24 hours for 10
days

4.0 Urinary Tract Infections
4.1. Asymptomatic bacteriuria (ASB)

4.1.1. Definition
Presence of bacteria in the urine (bacteriuria) in the absence of specific
symptoms of acute urinary tract infection. Common pathogens are
Escherichia coli, Proteus mirabilis and group B Streptococcus
4.1.2. Risks/complications
Persistent bacteriuria may lead to an increased risk of urinary tract
infections (cystitis and pyelonephritis) and these ones to an increased risk
of preterm birth and low birth weight
4.1.3. Diagnosis
• Midstream urine culture is the recommended method for diagnosing
ASB in pregnancy
• In settings where urine culture is not available, midstream urine Gram
staining is recommended over the use of dipstick tests
• Urine dipstick: if the urine dipstick shows only leucocytes, repeat
mid-stream sample after vulvar cleaning. If leucocytes are still present
after vulvar cleaning and even if no nitrites are present, treat as per
below regimes
4.1.4. Treatment
A seven-day antibiotic regimen is recommended for all pregnant clients
with asymptomatic bacteriuria
• Amoxicillin PO: 500 mg/8 h for 7 days
• Cefixime PO: 200 mg/12 h for 7 days
• Nitrofurantoin PO 100 mg/8 h for 7 days. Do not administer in weeks 38-42
(risk of neonatal haemolysis)

4.2. Cystitis
4.2.1. Definition
Symptomatic infection of the bladder
4.2.2. Clinical presentation

• Pain when urinating
• Increased frequency of urination
• Low abdominal pain
• Low grade temperature
4.2.3. Diagnosis
Same as ASB plus above mentioned symptoms
4.2.4. Treatment
Treatment is the same as for ASB
• Advise oral fluids at least 1.5 L/day

4.3. Pyelonephritis
4.3.1. Definition
Infection of the upper urinary tract affecting the kidneys

Symptoms of cystitis and:
• High fever
• Unilateral flank pain
• Abdominal tenderness
• Nausea or vomiting
4.3.3. Diagnosis
Same as cystitis plus above mentioned symptoms
4.3.4. Treatment
• Admit the patient
• Start IV fluids at least 150 ml/hour (1 L normal saline/Ringer’s lactate in
8 hours)
• Ampicillin 2 g IV every six hours PLUS gentamicin 5 mg/kg body weight
IV every 24 hours until client is 48 hours without temperature and is not
vomiting
OR
• Ceftriaxone slow IV injection 1 g once daily PLUS gentamycin 5 mg/kg
body weight IV every 24 hours
• After 48 hours without temperature and tolerating by mouth complete
10-14 days of oral treatment with amoxicillin-clavulanic 875/125 mg twice
daily for 10-14 days

5.0 H
ypertensive Disorders in
Pregnancy
5.1. Definition
• Hypertension in pregnancy is defined as systolic blood pressure (SBP)
≥140 mmHg and/or diastolic blood pressure (DBP) ≥ 90 mmHg, measured
twice (at least 15 minutes apart) while the client is rested and seated
• Severe hypertension is considered when the SBP is ≥160 mmHg and/or
DBP ≥110 mmHg
• The previous classification of mild and severe preeclampsia has been
replaced by preeclampsia with or without symptoms of severity (severe
features)
• Proteinuria is no longer the only determining feature in classifying the
severity of preeclampsia and absence of proteinuria does not discard
preeclampsia
An updated classification is included below

5.2. Classification and clinical presentation
Hypertensive disorders in pregnancy include are classified and described in Table 5
Table 5. Classification of hypertensive disorders in pregnancy
Chronic hypertension Elevation of BP before 20 weeks gestation or persisting after 12 weeks postpartum
Gestational hypertension Elevation of BP after 20 weeks gestation without proteinuria nor other signs of preeclampsia
Preeclampsia Hypertension after 20 weeks gestion AND ONE of the following:

• Proteinuria: ≥1+ in urine dipstick or 30 mg/dl in urine analysis
• Other maternal organ dysfunction, including:
– Acute kidney injury (creatinine ≥1 mg/d; 90 μmol/L)
– Liver involvement (elevated transaminases e.g. ALT or AST > 40 IU/L) with or without right upper
quadrant or epigastric abdominal pain)
– Neurological complications (examples include eclampsia, altered mental status, blindness,
stroke, clonus, severe headaches, persistent visual scotomata)
– Haematological complications (thrombocytopenia – platelet count below 150,000/μL, DIC,
haemolysis)
– Uteroplacental dysfunction (such as foetal growth restriction, abnormal umbilical artery Doppler
wave form analysis, or stillbirth)
Preeclampsia without Hypertension after 20 weeks AND only proteinuria (NO signs of organ damage NOR severe
severe features Hypertension (SBP is ≥160 mmHg and/or DBP (diastolic BP) ≥110 mmHg)
Preeclampsia with Hypertension after 20 weeks gestation WITH OR WITHOUT proteinuria AND any of the following:
severe features • Severe headache, tinnitus
• Visual disturbances
• Epigastric pain, vomiting, nausea
• Hyperreflexia
• Oliguria (<30 ml/hour)
• Pulmonary oedema
• Thrombocytopenia (<100000/mm3)
• Renal impairment (serum creatinine level > 1.1 mg/dl)
• Hepatic disfunction (doubling of GOT and GAT)
• HELLP syndrome: severe form of preeclampsia with haemolysis, elevated liver enzymes and low
platelets
Severe hypertension after 20 weeks AND proteinuria is considered preeclampsia with severe
features
Eclampsia Convulsions and high BP in pregnant clients > 20 weeks LMP
• Can occur regardless of the severity of the hypertension
• Can occur without previous signs and symptoms
• 25% occur in postpartum period
• Convulsions can be followed by coma of variable duration
Any pregnant or postpartum clients presenting with convulsions may be suspected of eclampsia
and subsidiary of magnesium sulphate until proven otherwise
Preeclampsia • Chronic essential hypertension that add any of the above-mentioned maternal organ dysfunction
superimposed upon consistent with preeclampsia
chronic hypertension Rises in blood pressure per se are not sufficient to diagnose superimposed preeclampsia, as such
rises are difficult to distinguish from the usual increase in blood pressure after 20 weeks’ gestation

Notes:
• Abnormally high proteinuria is no longer considered a severe feature in
preeclampsia. Nevertheless, if it is not possible to perform regular and
reliable monitoring of blood creatinine levels, heavy proteinuria (3+ or
more on dipstick urinalysis) should be considered as a criterion for
referral to a CEmONC facility
• In clients with proteinuria and no hypertension, consider urinary tract
infection, contamination of urine with blood or vaginal secretions or
nephropathy. In these cases, monitor to ensure early detection of
preeclampsia
• Preeclampsia can easily (and quickly) progress to preeclampsia with
severe features and/or eclampsia
5.3. Prevention of hypertensive disorders in

pregnancy (see Module 1)
• Calcium carbonate 1.25 g tabs (equivalent to 500 mg elemental Ca):
1 tablet 3 times per day (equivalent to a total dose of 1.5 elemental
calcium daily):
– Give to all clients in areas with low dietary calcium intake and high risk
of developing preeclampsia: obesity, previous preeclampsia, diabetes,
chronic hypertension, renal disease, autoimmune disease, nulliparity,
advanced maternal age, adolescent pregnancy and conditions leading
to hyperplacentation and large placentas (e.g. twin pregnancy). This is
not an exhaustive list but can be adapted/complemented based on the
local epidemiology of preeclampsia
– Start at 20 weeks gestation
• Low-dose acetylsalicylic acid (aspirin) 75 mg
– Give to all clients with high risk of developing preeclampsia (see above)
– Start ideally at 12 weeks gestation or at least before 20 weeks gestation

5.4. Treatment
• The aim is to achieve a blood pressure of around 140/90 +/-10 mmHg.
Lowering drastically the blood pressure can decrease placental perfusion
and have a negative impact on the foetus
• Do not administer ergometrine to a client with high BP
5.4.1. Gestational hypertension

• Outpatient management requires a doctor
• Weekly follow up with BP and proteinuria
• Monitor foetal growth and wellbeing
• Health advice: rest, normal calorie and sodium intake, educate on danger
signs (headache, epigastric pain, tinnitus, etc.)
• If SBP ≥ 160 mmHg and/or DBP ≥ 110 mmHg start on medication as per
below table
Table 6. Oral drugs for treatment of hypertension in pregnancy
Labetalol • Start dose 100 mg-200 mg/12 hours

• Gradual increases by 100 mg/dose
• Usual effective dose: 400 mg/12 hours
• If doses higher than 400 mg/12 hours are required: divide into 3 doses
• Maximum daily dosage: 24 g daily
• Contraindications: should not be given to clients with congestive heart failure, asthma or in shock
• If mother was taking labelatol around delivery: monitor newborn the first 72 hours of life for hypoglycaemia,
bradycardia and respiratory distress
Methyldopa • Start: 250 mg/8-12 hours
• Increase by 250 mg every 2-3 days
• Usual effective dosage: 500 mg/8 hours
• Max dose: 3 g/daily (1 g/8 hours)
Nifedipine • Nifedipine 10-20 mg retard /12 hours.
Due to secondary effects of nifedipine (headache, flushing, constipation, etc.) it is the third preferred option after
labetalol and methyldopa

5.4.2. Chronic hypertension
• Use the same drugs the client was using before pregnancy besides
following options that are contraindicated:
– Diuretics
– Angiotensin-converting-enzyme-inhibitors (e.g. enalapril)
– Angiotensin receptor blockers (e.g. irbesartan)
– Betablockers other than labetalol
– Calcium channel blockers other than nifedipine
• If a change of drugs is necessary due to above contraindications,
use the same drugs as for gestational hypertension
5.4.3. Preeclampsia without severe features but without good

BP control in outpatient
Table 7. Management of preeclampsia without severe features but

without good BP control in outpatient
<37 weeks without good BP control ≥37 weeks

• Admit into CEmONC: rest, monitoring Same as <37 weeks but start induction
of BP and proteinuria of labour as soon as Bishop score
• Screen for foetal growth restriction and is favourable or there is any sign of
wellbeing deterioration in the client’s condition
• In 24-34 weeks LMP: administer

corticosteroids for foetal lung
maturation
• Normal calorie and sodium intake
• If SBP≥160mmHg and/or
DBP≥110mmHg: start antihypertensive
treatment as per above
• Any evolution in proteinuria or signs of
severe preeclampsia: induce labour

5.4.4. Preeclampsia with severe features
• Admission in CEmONC with experienced team
• Monitor foetal growth and wellbeing
• Insert IV line and Foley catheter
• Monitor on hourly basis: BP, urinary output (Foley catheter), RR, HR, FHR
• Check full blood count, urinalysis, hepatic enzymes and creatinine
• Delivery needs to take place ideally in 24 hours (either by induction or
C-section) depending on gestational age and client’s condition. Refer/
manage in centre with appropriate neonatal care unit according to GA:
– <24 weeks: induction within 24 hours as soon as condition is stable
– 24-34 weeks: give antenatal corticosteroids
• If mother’s/foetus’ condition is stable: start induction at the end of the
corticoid course
• If mother’s/foetus’ condition is deteriorating start induction (or CS)
after first dose of corticosteroids. Refer to appropriate centre for
delivery and neonatal care
– >34 weeks: delivery within 24 hours ideally after stabilising condition
• Start magnesium sulphate for prevention of eclampsia (see below
dosages)
• Start antihypertensive treatment if SBP ≥ 160 mmHg and/or DBP ≥ 110
mmHg:
– Target is to lower BP below 160/110 but not below 140/90
– Preferred route is IV. If no iv access is possible, the oral route is
possible but not ideal
– See options below in descending order of preference

Table 8. Drugs for preeclampsia with severe features
IV route 1. Labetalol:
• Start with 20 mg IV (over 1 minute)
• If response is inadequate after 10 minutes: administer another 20 mg IV
• The dose can be doubled to 40 mg and then 80 mg with 10-minute intervals between each increased dose until
blood pressure is lowered below threshold
• The maximum total dose is 300 mg IV
• After controlling the acute hypertension, switch to oral treatment
• Do not administer to clients with congestive heart failure, asthma or in shock. Monitor newborn for 72 hours
after delivery for hypoglycaemia, respiratory distress and bradycardia
2. Hydralazine:
• Start with 5 mg IV slowly over 2-4 minutes
• Repeat every 20 minutes until the blood pressure goal has been achieved. The maximum dose is 20 mg per 24
hours (4 pushes IV)
• Switch to oral treatment when acute hypertension controlled
Oral route 1. Labetalol: start with 400 mg oral and repeat dose after one hour until goal BP is achieved (max dose 2400 mg
per 24 hours)
2. Methyldopa: start with 750 mg and repeat dose every 3 hours until goal BP is achieved (max dose 3 gr per 24
hours)
3. N
ifedipine: nifedipine immediate release tabs 10 mg orally. If target blood pressure is not achieved in 20
minutes (diastolic <110 mmHg but not <90 mmHg), administer 10 mg depending on initial response and repeat
blood pressure 20 minutes later; if target blood pressure is not achieved, administer another 10 mg. If target
blood is still not achieved in 20 minutes, then a switch to another agent is required (preferably labelatol IV).
NO SUBLINGUAL USE

5.4.5. Eclampsia
• Protect against injury, maintain airway (Goeddel airway), recovery position
• Insert IV line and Foley catheter
• Start magnesium sulphate as per below regimen. Continue treatment for
24 hours after delivery or after last seizure (whichever occurred more
recently)
• Oxygen 4-6 L/minute
• Treat BP as per preeclampsia with severe features
• Delivery within 12 hours:
– Vaginal delivery is possible for an eclamptic stabilised patient (evaluate
cervix, multi-primigravida, etc.)
– If C-S: spinal is preferred over ketamine
Table 9. MgSO4 regimens
Magnesium sulphate (MgSO4) for prevention and treatment of seizures associated with hypertensive disorders in
pregnancy
IV/IM option Loading dose: 4 g in 100 ml of NS (0.9% sodium chloride) infusion over 15-20 mins followed by;
Maintenance dose: 5 g IM in each buttock (total of 10 g). Followed by 5 g IM every 4 hours (alternate
injection sides)
Continue for 24 hours after delivery or after the last seizure (whatever happens last)
IV option Loading dose: 4 g in 100 ml of NS (0,9% sodium chloride) infusion over 15-20 min. FOLLOWED by
Maintenance dose: 1 g per hour by continuous iv infusion.
Continue for 24 hours after delivery or after the last seizure (whichever occurred more recently)
If recurrent seizure Administer additional 2 g MgSO4 iv over 15-20 min
during treatment
Monitoring during BP, HR, RR and patellar reflex every 15 min for the first hour, then every hour
MgSO4 treatment Urinary output every hour
STOP MgSO4 if • Any sign of overdose: disappearance of patellar reflex, hypotension, arrythmia, respiratory
depression (RR<12/min) and urinary output <30 ml/hour or 100 ml/4 hours
• Administer calcium gluconate 1g IV

6.0 Hyperglycaemia in
Pregnancy
6.1. Definitions
• Hyperglycaemia in pregnancy: medical condition resulting from
either pre-existing diabetes (known or unknown) or insulin resistance
developed during pregnancy
• Diabetes in pregnancy (DIP): refers to pre-existing diabetes mellitus
type 1 or 2 in a pregnant client. The condition is usually known before the
pregnancy but can also be diagnosed for the first time during pregnancy
• Gestational diabetes mellitus (GDM): insulin resistance developed
during pregnancy, usually after 20 weeks of gestation
• Fasting plasma glucose (FPG): plasma glucose after at least 8 hours
of overnight fasting
• Capillary blood glucose (CBG): capillary blood glucose measured
usually with a glucometer
• Oral glucose tolerance test (OGTT): diagnostic test in which glucose
is given orally and blood samples taken afterward at predetermined time
intervals to determine how quickly it is cleared from the blood
• Glycosuria: presence of glucose in the urine
6.2. Introduction
Hyperglycaemia in pregnancy is a frequent condition seen in 15-30% of
pregnancies depending on the context. Around 85% of hyperglycaemias
in pregnancy can be classified as gestational diabetes (GDM) and 15%
classified as diabetes in pregnancy (DIP)
GDM and DIP are associated with negative pregnancy outcomes and
with short, medium- and long-term adverse events for the mother and the
newborn
There is international consensus on the importance of identifying and
treating pregnant clients with GDM or DIP. However, there is no agreement
regarding the screening methods, the diagnostic cut-offs and the
management algorithms

The present chapter describes the diagnosis and management of GDM
and DIP in MSI obstetric centres. It is strongly influenced by the directives
given by WHO and FIGO in 2013 and 2015, as well as different country
models that aim to reduce the burden of screening tests and adapt to
medium and low resource settings (i.e. China, Ethiopia). These guidelines
are a compromise between the “golden standards” and the “ground
realities”
Ideally, all pregnant clients should be subject to a fasting plasma glucose
determination during the first trimester to exclude an unknown DIP and a
one-step fasting 75 g oral glucose tolerance test (OGTT) at week 24-28 of
gestation to screen for GDM
In the present guidelines, the urinalysis performed in the first trimester will
determine glycosuria as a proxy for DIP. Glycosuria in pregnancy is present
when blood sugar levels start to rise above 140 mg/dl (7.8 mmol/L) and will
be used as a first screening step
Further on, at 24-28 weeks gestation, a selective screening based on risk
factors1 and a two-step approach will determine which patients will need
an OGTT2. This approach allows for a considerable reduction in OGTTs
without excessively compromising the sensitivity of GDM detection
Regarding management of GDM, metformin will be the drug of choice
when diet and lifestyle changes are not enough to control glycaemia.
Clients with DIP and clients with GDM who require insulin will be referred
for interdisciplinary specialised management
1.
elective screening based on a set of risk factors will detect around 85% of all cases of
S
pregnant clients with GDM (FIGO 2015)
2.
This approach has been successfully used in China and Saudi Arabia and has proven
to reduce by more than 50% the amount of OGTTs, without compromising sensitivity of
detection (Agarwal 2015)

Diabetes during pregnancy is associated with short, medium- and long-
term adverse events and negative pregnancy outcomes for the mother and
the newborn. For GDM the incidence of complications is less prevalent and
usually less severe
Table 10. Summary of risks for pregnant clients with DIP
INCREASED RISKS TO THE MOTHER INCREASED RISKS TO FOETUS/

ASSOCIATED WITH DIP NEONATE/INFANT ASSOCIATED
WITH DIP
• Spontaneous abortions • Stillbirth and neonatal death
• Frequent urinary tract infections • Nonchromosomal congenital
• Pregnancy induced hypertension malformation
• Excessive foetal growth (macrosomia, • Shoulder dystocia and birth trauma

large for gestational age) • Cardiomyopathy
• Traumatic labour, instrumental delivery, • Respiratory distress
caesarean section • Neonatal hypoglycaemia
• Hydramnios • Neonatal polycythaemia
• Preterm labour • Neonatal hyperbilirubinemia
• Thromboembolism • Neonatal hypocalcaemia
• Postpartum infections • Long-term: recent evidence shows
• Long-term: weight retention, GDM in a higher frequency of diabetes,
subsequent pregnancies, future DM, obesity and metabolic syndromes in
future cardiovascular disease children and adults that were exposed
to hyperglycaemia during the foetal
period

6.4. Diagnosis
6.4.1. Classification of hyperglycaemia in pregnancy
Any hyperglycaemia first detected at any time during pregnancy should
be classified either as DIP or GDM as per below criteria (WHO 2013)
DIP
Diabetes mellitus type 1 or 2 pre-existing to pregnancy, either already
known or firstly discovered during pregnancy. DIP first discovered during
pregnancy has a higher risk of complications than GDM or DIP controlled
before pregnancy because of higher levels of hyperglycaemia before and
after conception
Criteria for DIP are:
• Fasting plasma glucose (FPG) ≥126 mg/dL or (≥7.0 mmol/L)
• AND/OR 2-hour 75-g oral glucose tolerance test (OGTT) value ≥200 mg/
dL (≥11.1 mmol/L)
• AND/OR a random plasma glucose (RPG) ≥200 mg/dL (≥11.1 mmol/L)
associated with signs and symptoms of diabetes
GDM
Hyperglycaemia detected first time during pregnancy that is not DIP,
most frequently after 24 weeks GA
Criteria for GDM are:
• FPG 92−125 mg/dL (5.1−6.9 mmol/L)
• AND/OR 1-hour post 75-g OGTT ≥180 mg/dL (≥10 mmol/L)
• AND/OR 2-hour post 75-g OGTT 153−199 mg/dL (8.5–11.0 mmol/L)

6.4.2. Screening
• During the first ANC contact a set of risk factors must be assessed
to decide which clients will be screened at 24-28 weeks gestation.
Additionally, a urinalysis will be carried out to detect glycosuria (see
Module 1). The following table summarises the risk factors for the selective
screening and the below algorithm describes in detail the diagnostic
pathway. The golden standard is the 75g OGTT, however it is time
consuming and labour-intensive for clients and staff. If a FPG is done as
first step with a cutoff of 80 mg/dl, 33-50% of all OGTTs can be avoided
• Technical considerations on glucose measurements: glucose
measurements should be ideally performed in accredited laboratories
using properly transported venous plasma samples. When this is not
possible, a plasma-calibrated handheld glucometer (with safely stored
test strips) can be used. Once a quarter, a few blood samples are tested
in parallel in an accredited laboratory to document the reliability and
accuracy of the glucometer
Table 10. Risk factors for selective screening of hyperglycaemia in

pregnancy
RISK FACTORS (TO BE CHECKED AT FIRST ANC CONTACT)

• BMI > 30 (calculated as weight in kg divided by height in meters squared)
• Previous pregnancy with GDM
• Previous or current pregnancy with a macrosomic baby (weight ≥4500g)
• Previous pregnancy with stillbirth or IUFD
• Previous congenital malformation
• Maternal age > 35 years
• First degree relative with diabetes
At any ANC contact: clients with glycosuria of ≥2+ on one occasion or ≥1+ on two or
more occasions (detected by reagent strip testing) in the current pregnancy

Figure 4. Screening and diagnostic algorithm for hyperglycaemias in pregnancy
1 or more risk factors in Table 1 present?
YES NO
Test FPG at week 24-28 No testing for GDM

Continue routine ANC
schedule
If glycosuria of ≥2+ on one
occasion or ≥1+ on two or
more occasions above 28

weeks: perform FPG and
FPG ≤80 mg/dl (≤4.4 FPG 81-91 mg/dl (4.5-5 FPG 92-125 mg/dl (5.1- FPG >125 mg/dl (>6.9
follow algorithm
mmol/L) mmol/L) 6.9 mmol/L) mmol/L)
No further test needed. Perform a fasting 75 g No further test needed No further test needed
Routine ANC 2-hour OGTT Diagnosis of Diagnosis of diabetes
gestational diabetes in pregnancy (DIP)
(GDM)
Diagnosis of GDM if any of the below Diagnosis of DIP if 2-hour post 75-g
• 1-hour post 75-g oral glucose load oral glucose tolerance test (OGTT)
≥180 mg/dL (≥10 mmol/L) or value ≥200 mg/dL (≥11.1 mmol/L)
• 2-hour post 75-g oral glucose load
153−199 mg/dL (8.5–11.0 mmol/L)
2.36
6.5. Management during antenatal care
6.5.1. Referral to higher level
Due to their increased risk of complications all the following cases will be
referred to higher level for appropriate management during ANC (tertiary
hospital with multidisciplinary team). It is possible to conduct client follow
up during ANC in our CEmONC centres if the client is simultaneously being
visited by a diabetes specialist. However, delivery will be scheduled in a
tertiary hospital with a multidisciplinary team
Table 11. Criteria for referral to higher level in pregnant clients with
hyperglycaemia in pregnancy
REFERRAL DURING ANC AFTER SCREENING OF HYPERGLYCAEMIA IN

PREGNANCY
• All pregnant clients diagnosed with pre-GDM (either during current pregnancy
or before)
• Diagnosis of diabetes (GDM or PID) < 20 weeks of gestation
• Need for pharmacologic therapy for hyperglycaemic control >30 weeks
• Fasting plasma glucose levels at screening >110 mg/dL
• 1-hour postprandial glucose at screening >140 mg/dL
• Pregnancy weight gain >12 kg at week 24-28
All clients diagnosed with GDM that continue ANC in MSI obstetric centres
will be followed up by a doctor and must deliver in a CEmONC. Wherever
possible clients will be visited in parallel by a diabetic specialist

6.5.2. Diet and lifestyle
Nutrition intervention and physical activity are the primary tools in the
management of GDM. Nutrition intervention, physical activity and weight
management can control 75-80% of mild to moderate GDM
All clients with GDM must receive practical education that allows them to
choose the right quantity and quality of food adjusted to their personal and
cultural preferences. It is important to highlight that the same healthy eating
habits should be continued even after delivery to reduce the long-term risk
of developing type 2 DM
Recommendations are:
• Reduce consumption of processed, high sugar, high fat, high salt and low
fibre foods. Stop sugar-sweetened beverages (i.e. soft drinks, fruit drinks)
• Non-caloric sweeteners such as aspartame and sucralose may be used
in moderation. Saccharine is not recommended as it crosses the placenta
• The daily energy intake should be approximately 2050 calories in all BMI
categories. Stricter diets can be given to obese clients (BMI >30), but they
should never be below 1800 kcal/day
• Calorie intake per meal should be distributed in 3 small to moderate
meals (breakfast 10-15% of total calory intake, lunch 30%, dinner 25-
30%) and 2-3 snacks in between (all of them 30% of total calorie intake)
• Limit the carbohydrate intake to 35-45% of the total calories. A minimum
of 175 g carbohydrates/day should be provided, and they should be
distributed throughout the day in three small- to moderate-sized meals
and 2−4 snacks. An evening snack may be needed to prevent accelerated
ketosis overnight
• A minimum of 71 g of proteins and 28 g of fibre should be provided
• Educate the client in the recognition and management of hypoglycaemia
– Signs of hypoglycaemia: sweating, dizziness, feeling hungry, tired,
shaky or trembling
– Management: ingest 15 g of simple carbohydrates (i.e. sugar or
sweetened liquids)
• Lifestyle: at least 30 minutes per day of planned physical activity must
be recommended
• Weight follow up: after prescribing the diet, it is important to pay
attention to subsequent changes in weight. Weight gain should follow the
below table (IOM 2009)

Table 11. Weight gain during pregnancy according to BMI
Pregnancy BMI Total weight gain in Mean rates of weight

pregnancy gain in 2nd and 3rd
trimester (kg/weeks)
< 18.5 12.5-18 kg 0.51 kg/week
18.5-24.9 11.5-16 kg 0.42 kg/week
25-29.9 7-11.5 kg 0.28 kg/week
≥ 30 5-9 kg 0.22 kg/week
6.5.3. Drug therapy

Insulin treatment is the preferred choice in most country protocols,
however we believe that oral antihyperglycemic agents are a reasonable
alternative for clients who fail nutritional therapy and can be managed by the
obstetrician. Metformin has proven to be the safest and the most effective.
When metformin alone does not control glycaemia, the client will be referred
to multi-disciplinary care to start insulin therapy
Metformin must be started in clients with:

• FPG ≥ 95 mg/dl (> 5.1 mmol/L) OR
• 2-hour postprandial plasma glucose ≥ 120 mg/dl (>6.7 mmol/L)
• No improvement after 2 weeks of dietary measures
Dosage:
• Week 1: 500 mg once daily in the morning at breakfast
• Week 2: 500 mg 2 times daily (morning and evening) during meals
• Increase in increments of 500 mg per week as long as the drug is well
tolerated to a maximum of 2 g daily (i.e. 1 g morning and evening)
Secondary effects of metformin include diarrhoea, flatulence,

abdominal pain, and feelings of weakness and muscle pains

6.5.4. Antenatal follow up
• Foetal growth surveillance and wellbeing (clinical and US) every 2 weeks
from diagnosis until term
• Glucose control
The glycaemic targets during ANC are:

✓ FPG < 95 mg/dl (< 5.1 mmol/L) OR
✓ One-hour postprandial blood glucose concentration: <140 mg/dL
(7.8 mmol/L)
✓ Two-hour postpandrial blood glucose concentration <=120 mg/dl (6,7
mmol/L)
FPG or postprandial glucose determination can be chosen depending on
the client’s personal and cultural preferences, however the postprandial
ones are preferred whenever possible as abnormal levels have been
stronger correlated with macrosomia than fasting glucose levels
The following algorithm summarises the monitoring pathway of GDM during

ANC. The follow up pathway for DIP is not included as it is recommended to
refer these clients for specialised care and insulin management

Figure 5. Monitoring and management of GDM during ANC
Check FBG or postprandial glucose after 2 weeks of diet and physical activity
FPG ≥ 95 mg/dl (> 5.1 mmol/L) OR 2-hour FPG < 95 mg/dl (<5.1 mmol/L) OR 2-hour
postprandial plasma glucose ≥ 120 mg/dl postprandial plasma glucose < 120 mg/dl
(>6.7 mmol/L) (< 6.7 mmol/L)
Start metformin 500 mg once daily in the morning Continue follow up visits every 2 weeks with FBG
at breakfast or postprandial glucose checks
Follow up in 1 week FPG < 95 mg/dl (< 5.1 mmol/L) OR 2-hour

postprandial plasma glucose < 120 mg/dl
(<6.7 mmol/L)
FPG ≥ 95 mg/dl (> 5.1 mmol/L) OR2-hour

postprandial plasma glucose ≥ 120 mg/dl
(>6.7 mmol/L) Continue follow up visits every 2 weeks with FBG
or 2 hour postprandial glucose checks
Increase metformin with weekly follow ups up to a

máximum of 2g daily
If still no glycaemic control achieved: refer for insulin

treatment

6.6. Management during delivery
6.6.1. Timing and mode of delivery
• For clients who are diagnosed with GDM or DIP, delivery needs to take
place in a CEmONC
• Careful foetal weight estimations with US by an experienced provider will
determine timing and mode of delivery as per below algorithm. Note that
weight estimations on ultrasound can be 15% higher/lower than actual
foetal weight even if measures are done correctly
Figure 6. Timing and mode of delivery in GDM
Between 38 and 39 weeks
< 3800 gr 3800-4000 g >4000 g

estimated foetal weight estimated foetal weight estimated foetal weight
• Poor glycaemic control or poor

compliance with management
• Previous stillbirth or neonatal YES
death
• Cardiovascular disease
NO
Induction of labour at 40 weeks Induction of labor at 38-39 weeks Consider elective C-S

6.6.2. Glucose control during labour and delivery
• Target for glucose control during labour and delivery is 72−126 mg/dL
(4–7 mmol/L) to avoid neonatal hypoglycaemia
• The majority of clients with GDM are controlled successfully with diet and/
or metformin and will not require specific measures during labour and
delivery. Only less than 10% will require an insulin infusion
• During latent phase of labour: allow client to follow her usual diet and
medication. Check capillary blood glucose every 4 hours
• During active phase of labour:
– Administer glucose 5% solution to prevent maternal hypoglycaemia
(1000 ml every 8 h; 125 ml/hour)
– Measure capillary blood glucose levels (CBG) every hour with
glucometer
– If glucose < 63 mg/dl (< 3.5 mmol/L): increase glucose infusion or allow
for a light meal
– If glucose > 126 (7 mmol/L): start a second infusion with sodium
chloride 0.9% 100 mL with 100 units actrapid insulin therefore 1
unit =1mL. Start with 1 ml/hour and adjust according to below table
depending on the result of hourly CBG. Usually rates between 0.5 ml/
hour to 1 ml/hour are enough to control glycaemia
– It is important that the maintenance infusion of glucose 5% remains
stable at 125 ml/hour to achieve a constant rate of glucose supply
– If CBG >15: refer the client to tertiary facility for further management
Table 12. Insulin infusion during labour
ADJUSTMENT OF INSULIN INFUSION DURING LABOUR ACCORDING TO CBG

CBG mL per hour unit per hour
< 63 mg/dl (<3.5 mmol/L) 0.0 0.0
63 -90 mg/dl (3.5 – 5 mmol/L) 0.5 0.5
91 – 126 mg/dl (5.1-7 mmol/L) 1 1
127-162 mg/dl (7.1 – 9 mmol/L) 2 2
163-198 mg/dl (9.1 – 11 mmol/L) 3 3
199-234 mg/dl (11.1 – 13 mmol/L) 4 4
235-270 mg/dl (13.1 – 15 mmol/L) 5 5

• Elective caesarean section:
– Schedule C-S early morning and allow for the client to take medication
and follow their usual diet the night before
– Client will be fasting overnight and will not take their usual metformin
dosage in the morning
– On admission start a 5% glucose infusion and follow protocol as for
labour
• Neonate:
– If the client’s blood sugar level have been kept between 72−126 mg/
dL (4–7 mmol/L) during labour the risk of neonatal hypoglycaemia is
relatively low
– Check neonate’s blood glucose within one hour of birth with glucometer
– If blood glucose is normal (≥ 45 mg/dl or ≥ 2.5 mmol/l): monitor
adequate breastfeeding (on demand, at least every 3 hours). Check
blood glucose before each meal or every 2 hours until there are 3
consecutive normal results
– If blood glucose is < 45 mg/dl or < 2.5 mmol/l: See management of
neonatal hypoglycaemia (see Module 7)
6.7. Management during postpartum period

• Usually glucose levels drop drastically after delivery and especially when
breastfeeding is started
• Check capillary blood glucose every 4 hours the first 24 hours postpartum
• Stop metformin but maintain diet and exercise as per antenatal
recommendations
• Encourage exclusive breastfeeding
• Inform about increased risk of GDM in subsequent pregnancy (up to two
thirds of clients with with GDM will have GDM again in the next pregnancy)
• Provide PPFP counselling: clients that are not diabetic after a pregnancy
with GDM can use any of the usually offered contraceptive methods
• After 6-12 weeks postpartum perform an OGTT. 15% of clients with
GDM will remain glucose intolerant; if this is the case refer for further
management to endocrinologist

7.0 Venous Thromboembolism
in Pregnancy
7.1. Definition
Venous thromboembolism (VTE) in pregnancy describes deep vein
thrombosis and pulmonary embolism
Pregnancy is a major risk factor for any VTE, increasing its risk in
comparison with non-pregnant clients almost tenfold
Approximately 1 in 1000 pregnancies will be complicated by VTE and
therefore appropriate prophylaxis, diagnosis and management is key
to avoid maternal complications and mortality
The present chapter focuses mainly on the prophylaxis of VTE in
pregnancy and postpartum. Any VTE suspicion needs immediate
referral to higher specialised care
7.2. Risk factors

Risk factors for VTE can be pre-existing to pregnancy or appear during
pregnancy (refer to Table 13)

Table 13. Risk factors for VTE in pregnancy and puerperium
Adapted from RCOG (2015)
Pre-existing risk factors Previous VTE

(before pregnancy)
Thrombophilia Heritable:
• Antithrombin deficiency
• Protein C deficiency
• Protein S deficiency
• Factor V Leiden
• Prothrombin gene mutation
Acquired:
• Antiphospholipid antibodies
• Persistent lupus anticoagulant and/or persistent moderate/high titre of
anticardiolipin antibodies and/or b-glycoprotein antibodies
Medical comorbidities, i.e. cancer, heart failure, active systemic lupus erythematosus,
inflammatory polyarthropathy, nephrotic syndrome, type I diabetes mellitus with nephropathy,
sickle cell disease, current intravenous drug user
Age > 35 years
Obesity: BMI ≥ 30 kg/m2 in early pregnancy or pre-pregnancy
Parity ≥ 3
Smoking
Gross varicose veins (symptomatic or above knee or with associated phlebitis, oedema/skin
changes)
Paraplegia
Obstetric risk factors Multiple pregnancy
Current preeclampsia
Caesarean section
Prolonged labour > 24 hours
Stillbirth
Preterm birth
PPH > 1 L requiring transfusion
New onset/transient Any surgical procedure during pregnancy or postpartum period except immediate perineal repair
Bone fracture during pregnancy or postpartum period
Hyperemesis, dehydration
Ovarian hyperstimulation syndrome
Assisted reproductive technology
Admission or immobility of ≥ 3 days bed rest (i.e. preterm labour with absolute bed rest
indication)
Current systemic infection that requires admission and intravenous antibiotics
Long distance travel > 4 hours

7.3. Diagnosis
7.3.1. Clinical history and examination
• Signs of deep vein thrombosis include
– Unilateral leg pain with or without swelling
– Increased calf diameter
– Pitting oedema
– Prominent superficial veins
– Skin that is warm to the touch, red, or even discoloured
A blood clot in a deep vein thrombosis can migrate to the lungs
and cause a pulmonary embolism
• Signs and symptoms of a pulmonary embolism include
– Difficulty breathing (dyspnoea)
– Chest pain that worsens with a deep breath or cough
– Coughing up blood (haemoptysis)
–T achycardia/palpitations or irregular heartbeat
–H ypotension and collapse

If available, D-dimer can support the diagnosis
7.3.3. Imaging:
• Deep vein thrombosis:
– Compression US and Doppler of the calf and in cases of doubt MRI
• Pulmonary Embolism:
– Chest X-ray: to discard any other pathologies that could explain the
symptoms (i.e. pneumonia)
– Ventilation/perfusion scan is the usually recommended study to confirm
a pulmonary embolism after a normal chest X-ray

7.4. Prophylaxis
During antenatal care, all pregnant clients should be assessed for risk
factors of VTE. During admission, delivery and postpartum period the client
must be re-assessed to determine their need for prophylactic treatment
with low molecular weight heparin (LMWH)
The following algorithm (Figure 7) summarises the risk factors (and their
combination) that will determine if, when and how to initiate prophylactic
LMWH for VTE. Any client who qualifies for LMWH prophylactic treatment
needs to be followed up by a doctor and deliver in a CEmONC

Figure 7. LMWH prophylaxis according to risk factors during ANC and labour. Source: RCOG green-top guidelines No. 37, April 2015
Appendix I: Obstetric thromboprophylaxis risk assessment and management
Antenatal assessment and management Postnatal assessment and management

(to be assessed at booking and repeated if admitted) (to be assessed on delivery)
Any previous VTE except a single event related to Any previous VTE
major surgery
HIGH RISK HIGH RISK
Anyone requiring antenatal LMWH
Requires antenatal
High-risk thrombophilia At least 6 weeks’ postnatal
prophylaxis with LMWH
prophylactic LMWH
Low-risk thrombophilia + FHx
Refer to trust-nominated
Hospital admission thrombosis in pregnancy
Single previous VTE related to major surgery expert/team
High-risk thrombophilia + no VTE Caesarean section in labour
Medical comorbidities e.g. cancer, heart failure, BMI ≥ 40 kg/m2
active SLE, IBD or inflammatory polyarthropathy, INTERMEDIATE RISK
Readmission or prolonged admission (≥ 3 days)
nephrotic syndrome, type I DM with nephropathy,
sickle cell disease, current IVDU INTERMEDIATE RISK in the puerperium At least 10 days’ postnatal
Consider antenatal prophylactic LMWH
Any surgical procedure e.g. appendicectomy Any surgical procedure in the puerperium except
prophylaxis
immediate repair of the perineum NB If persisting or > 3 risk

OHSS (first trimester only)
Medical comorbidities e.g. cancer, heart failure, factors consider extending
thromboprophylaxis with
active SLE, IBD or inflammatory polyarthropathy;
LMWH
Obesity (BMI > 30 kg/m2) Four or more risk factors: nephrotic syndrome, type I DM with
Age > 35 prophylaxis from first trimester nephropathy, sickle cell disease, current IVDU
Parity ≥ 3 Three risk factors:
Smoker prophylaxis from 28 weeks
Gross varicose veins Age > 35 years Two or more risk factors
Current pre-eclampsia Obesity (BMI ≥ 30 kg/m2)
Fewer than three risk factors
Immobility, e.g. paraplegia, PGP Parity ≥ 3
Family history of unprovoked or estrogen-provoked Smoker Fewer than two risk factors
VTE in first-degree relative
Elective caesarean section
Low-risk thrombophilia LOWER RISK Family history of VTE
Multiple pregnancy Mobilisation and avoidance of
Low-risk thrombophilia
IVF/ART dehydration LOWER RISK
Gross varicose veins
Early mobilisation and
Current systemic infection avoidance of dehydration
Transient risk factors:
Immobility, e.g. paraplegia, PGP, long distance travel
Dehydration/hyperemesis; current systemic
infection; long-distance travel Current pre-eclampsia
Antenatal and postnatal prophylactic dose of LMWH
Multiple pregnancy Weight < 50 kg = 20 mg enoxaparin/2500 units
dalteparin/3500 units tinzaparin daily
Preterm delivery in this pregnancy (< 37+0 weeks)
APL = antiphospholipid antibodies (lupus anticoagulant, anticardiolipin antibodies, β2-glycoprotein 1 antibodies); ART = assisted Weight 50–90 kg = 40 mg enoxaparin/5000 units
reproductive technology; BMI based on booking weight; DM = diabetes mellitus; FHx = family history; gross varicose veins = Stillbirth in this pregnancy dalteparin/4500 units tinzaparin daily
symptomatic, above knee or associated with phlebitis/oedema/skin changes; high-risk thrombophilia = antithrombin deficiency, protein Weight 91–130 kg = 60 mg enoxaparin/7500 units
C or S deficiency, compound or homozygous for low-risk thrombophilias; IBD = inflammatory bowel disease; immobility = ≥ 3 days; Mid-cavity rotational or operative delivery dalteparin/7000 units tinzaparin daily
IVDU = intravenous drug user; IVF = in vitro fertilisation; LMWH = low-molecular-weight heparin; long-distance travel = > 4 hours; low- Weight 131–170 kg = 80 mg enoxaparin/10 000 units
Prolonged labour (> 24 hours)
risk thrombophilia = heterozygous for factor V Leiden or prothrombin G20210A mutations; OHSS = ovarian hyperstimulation syndrome; dalteparin/9000 units tinzaparin daily
PGP = pelvic girdle pain with reduced mobility; PPH = postpartum haemorrhage; thrombophilia = inherited or acquired; VTE = venous PPH > 1 litre or blood transfusion Weight > 170 kg = 0.6 mg/kg/day enoxaparin/ 75 u/kg/
thromboembolism. day dalteparin/ 75 u/kg/day tinzaparin
2.49
7.4.1. Prophylactic dose of LMWH (enoxaparin or dalteparin)
Weight < 50 kg 20 mg enoxaparin 2500 units dalteparin
Weight 50–90 kg 40 mg enoxaparin 5000 units dalteparin
Weight 91–130 kg 60 mg enoxaparin 7500 units dalteparin
Weight 131–170 kg 80 mg enoxaparin 10 000 units dalteparin
Weight > 170 kg 0.6 mg/kg/day enoxaparin 75 u/kg/day dalteparin
7.5. Management of clients under LMWH

prophylaxis
• Clients receiving antenatal LMWH should be advised that if they have any
vaginal bleeding or once labour begins they should not inject any further
LMWH
• Regional anaesthesia techniques (spinal block) should be avoided
if possible until at least 12 hours after the previous prophylactic dose
of LMWH
• When a client presents while on a therapeutic regimen of LMWH,
regional techniques should be avoided if possible, for at least 24 hours
after the last dose of LMWH
• Clients receiving antenatal LMWH having an elective C-S should receive
a thromboprophylaxis dose of LMWH on the day prior to delivery and,
on the day of delivery, any morning dose should be omitted, and the
operation performed that morning
• The first prophylactic dose of LMWH should be given as soon as possible
after delivery provided there is no postpartum haemorrhage and regional
analgesia has not been used
• LMWH should not be given for 4 hours after use of spinal anaesthesia
• If a client develops a haemorrhagic problem while on LMWH the
treatment should be stopped, and expert haematological advice sought
(referral if stable)
• Thromboprophylaxis should be started or reinstituted as soon as the
immediate risk of haemorrhage is reduced
• Pregnant or postpartum clients with VTE (especially pulmonary oedema)
need immediate referral to higher specialised care (haematologist,
intensive care unit)

8.0 References
• World Health Organization, editor. WHO recommendations on antenatal care for a positive pregnancy
experience. Geneva: World Health Organization; 2016.
• Managing complications in pregnancy and childbirth: a guide for midwives and doctors – 2nd ed. Geneva: World
Health Organization; 2017. Licence: CC BY-NC-SA 3.0 IGO
• Pregnancy, Childbirth, Postpartum and Newborn Care A Guide for Essential Practice - 3rd ed. World Health
Organization; 2016.
• Essential obstetric and newborn care. Geneva: Médecins Sans Frontières; 2019.
• Brown MA, Magee LA, Kenny LC, Karumanchi SA, McCarthy FP, Saito S, et al. The hypertensive disorders
of pregnancy: ISSHP classification, diagnosis & management recommendations for international practice.
Pregnancy Hypertension [Internet]. 2018 Jul [cited 2020 Sep 22];13:291–310. Available from: https://linkinghub.
elsevier.com/retrieve/pii/S2210778918301260
• World Health Organization. WHO recommendations: drug treatment for severe hypertension in pregnancy
[Internet]. Geneva: World Health Organization; 2018 [cited 2020 Sep 17]. Available from: https://www.ncbi.nlm.
nih.gov/books/NBK535778/
• World Health Organization. WHO recommendations for prevention and treatment of preeclampsia and eclampsia.
[Internet]. 2011 [cited 2020 Jun 30]. Available from: http://whqlibdoc.who.int/publications/2011/9789241548335_
eng.pdf
• World Health Organization. WHO recommendations: drug treatment for severe hypertension in pregnancy
[Internet]. Geneva: World Health Organization; 2018 [cited 2020 Sep 17]. Available from: https://www.ncbi.nlm.
nih.gov/books/NBK535778/
• World Health Organization. WHO guideline on syphilis screening and treatment for pregnant women. [Internet].
2017 [cited 2020 Oct 16]. Available from: http://www.ncbi.nlm.nih.gov/books/NBK499742/
• World Health Organization. WHO guidelines for the treatment of treponema pallidum (Syphilis). [Internet]. 2016
[cited 2020 Oct 16]. Available from: http://www.ncbi.nlm.nih.gov/books/NBK384904/
• Walker GJA, Walker D, Molano Franco D, Grillo‐Ardila CF. Antibiotic treatment for newborns with congenital
syphilis. Cochrane Database of Systematic Reviews 2019, Issue 2. Art. No.: CD012071. DOI: 10.1002/14651858.
CD012071.pub2.
• Hod M, Kapur A, Sacks DA, Hadar E, Agarwal M, Di Renzo GC, Cabero Roura L, McIntyre HD, Morris JL,
Divakar H. The International Federation of Gynecology and Obstetrics (FIGO) Initiative on GDM mellitus: A
pragmatic guide for diagnosis, management, and care. Int J Gynaecol Obstet. 2015 Oct;131 Suppl 3:S173-211.
doi: 10.1016/S0020-7292(15)30033-3. PMID: 26433807.
• Agarwal MM. GDM mellitus: An update on the current international diagnostic criteria. WJD 2015;6(6):782–11.

• American Diabetes Association. Management of DIP. Diabetes Care 2016;39 Suppl 1:S94–8.
• Pertot T, Molyneaux L, Tan K, Ross GP, Yue DK, Wong J. Can common clinical parameters be used to identify
patients who will need insulin treatment in GDM mellitus? Diabetes Care 2011;34(10):2214–6.
• Kitwitee P, Limwattananon S, Limwattananon C, et al. Metformin for the treatment of GDM: An updated meta-
analysis. Diabetes Research and Clinical Practice 2015;109(3):521–32.
• Balsells M, Garcia-Patterson A, Sola I, Roque M, Gich I, Corcoy R. Glibenclamide, metformin, and insulin for the
treatment of GDM: a systematic review and meta-analysis. BMJ 2015;350(jan21 14):h102–2.
• Ryan, E.A., Al-Agha, R. Glucose Control during Labor and Delivery. Curr Diab Rep 14, 450 (2014). https://doi.
org/10.1007/s11892-013-0450-4
• Harold W. de Valk, Gerard H.A. Visser. Insulin during pregnancy, labour and delivery. Best Practice & Research
Clinical Obstetrics & Gynaecology, Volume 25, Issue 1, 2011, Pages 65-76. ISSN 1521-6934. https://doi.
org/10.1016/j.bpobgyn.2010.10.002.
• Ryan EA, Sia WW, Khurana R, Marnoch CA, Nerenberg KA, Ghosh M. Glucose Control During Labour
In Diabetic Women. Journal of Obstetrics and Gynaecology Canada [Internet]. 2012 Dec [cited 2020 Oct
27];34(12):1149–57. Available from: https://linkinghub.elsevier.com/retrieve/pii/S1701216316354627
• Kalra, P., & Anakal, M. (2013). Peripartum management of diabetes. Indian journal of endocrinology and
metabolism, 17(Suppl 1), S72–S76. https://doi.org/10.4103/2230-8210.119510
• National Institute for Health and Care Excellence (NICE) (2015) Clinical Guidance. DIP: management of diabetes
and its complications from preconception to the postnatal period.
• Canberra Hospital and Health Services (2018). Clinical Procedure. Insulin infusion for labour and birth.
• Durnwald C. GDM mellitus: glycemic control and maternal prognosis. In: UpToDate, Post, TW (Ed), UpToDate,
Waltham, MA, 2020.
• Institute of Medicine. Weight gain during pregnancy: reexamining the guidelines . Washington, DC: National
Academies Press; 2009.

Module 31
Antenatal Care
Intrapartum Care for
Normal Labour and
Vaginal Delivery
Module 3: Intrapartum Care
for Normal Labour and Vaginal
Delivery
Module contents
1.0 Stage of Labour 3.2
2.0 Diagnosis of Labour 3.3

2.1. Client history 3.3
2.2. Physical examination 3.3
3.0 Clinical Care for Each Stage of Labour 3.4

3.1. Active phase of first stage of labour 3.6
3.2. Second stage of labour 3.8
3.3. Third stage of labour 3.9
3.4. The use of partograph 3.10
3.5. Foetal monitoring 3.12
4.0 Analgesia During Labour and Delivery 3.14

4.1 Non-pharmacological pain management 3.14
4.2 Pharmacological pain management 3.15
5.0 Respectful Maternity Care 3.17
6.0 S
ummary of Dos and Don’ts 3.19
During Intrapartum Care
7.0 References 3.20

1.0 Stage of Labour
The stages of labour are described in Table 1. Please note that the traditional
cut-offs and durations for the first and second stages of labour have been
changed according to the latest international recommendations (WHO 2018)
Table 1. Stages of labour
First stage of labour Latent first stage • Painful uterine contractions and cervical changes up to 5 cm
• Variable duration
• Medical interventions to accelerate labour before 5 cm (provided there are no
other maternal or foetal indications) are not indicated
Active first stage • Painful uterine contractions and more rapid cervical dilatation from 5 cm until
full dilatation
• The duration of active first stage usually does not extend beyond 12 hours in
first labours and beyond 10 hours in subsequent labours
• A minimum cervical dilatation rate of 1 cm/hour throughout active first stage
is unrealistically fast for some clients and is therefore not recommended for
identification of normal labour progression
• A slower than 1 cm/hour cervical dilatation rate alone should not be a
routine indication for an obstetric intervention
Second stage of labour • Period of time between full cervical dilation and birth of the baby. The client experiences an
involuntary urge to bear down, as a result of expulsive uterine contractions
• Primigravidas: variable duration up to 3 hours
• Multigravidas: variable duration up to 2 hours
• Medical interventions (in absence of any anomaly) are not indicated before these timings
Third stage of labour Period between delivery of the baby and delivery of placenta and membranes
Average duration is 5-15 minutes. Durations above 30-45 minutes (without PPH) require intervention
Fourth stage of labour/ First 2 hours after birth
immediate postnatal
period

2.0 Diagnosis of Labour
2.1. Client history

If the client was followed in ANC, retrieve and analyse the ANC records
• LMP and confirmed EDD
• Start of contractions and frequency
• Rupture of membranes, and if so, colour of the liquor
• Foetal movements
• Any abnormal discharge or bleeding
• Previous clinical history (any medications, pathologies, or allergies)
• Previous obstetric history
• Fill out the MSI Risk Evaluation Form
2.2. Physical examination

• Abdominal palpation: fundal height, foetal lie, presentation, and descent
• Foetal wellbeing: FHR with doppler or Pinard for 1 minute and ideally during
and after a contraction
• Vaginal exam:
– Any evidence of amniotic liquor
– Presence/absence of membranes
– Cervical consistency, position, effacement, and dilatation
– Position of presenting part, descent, and station in relation to ischial
spines (see below)
If the cervix is dilated >5 cm:

• Explain findings to the client, answer questions, give advice on pain
management
• Admit to labour ward and start partograph
If the cervix is <5 cm and membranes intact with no other findings:

• Explain findings to the client, answer questions, give advice on pain
management
• Assess whether to admit (primi- or multi-gravida, pain, frequency of
contractions, distance to home)

3.0 C
linical Care for Each Stage
of Labour
The following table outlines the main observations and actions required in
each stage for uncomplicated normal labour. Further details are provided
afterwards
All information must be recorded in the client’s chart and partograph
In an uncomplicated uneventful labour and delivery, the client’s wishes, and
preferences should be always respected (see Section 5.0 on respectful
maternity care)

Table 2. Clinical care in each stage of labour
Latent phase of first • If the client is admitted, provide active communication and support
stage of labour • Advice for deambulation
• Monitor vital signs, contractions, and FHR every 6 hours
• Vaginal exam: only when client complains of increase in contractions, rupture of membranes or
bleeding
Active phase first • Follow partograph completion
stage of labour • Every 4 hours:
– Vital signs (Tª, BP, RR, HR)
– Vaginal exam: cervical dilatation, foetal descent (see below)
– Colour of amniotic fluid
– Urine output
• Every 30 min:
– Contractions
– Foetal monitoring
– Record any medication and fluids
• Insert IV line in clients with any risk factor (hypertension, obstetric antecedents, abnormal foetal
monitoring, etc.)
• Assess pain and offer pain management options
• Allow the client to mobilise, walk, eat lightly and drink
• Active communication and support
Second stage of • Follow partograph completion
labour • Ensure an empty bladder (encourage client to pass urine)
• Assess pain and offer pain management options
• Monitor urge to push and allow for pushes with each contraction
• Monitor FHR after each contraction or every 5 minutes (whatever is earlier)
• Allow for different birth positions and birth companion to be actively involved (massage, help in
positioning the client, etc.)
• In delivery: avoid routine episiotomy and provide perineal support techniques
Third stage of labour • Active management of third stage of labour (10 IU oxytocin IM/slow IV stat)
• Delayed cord clamping in all healthy newborns (1-3 min)
• Immediate skin to skin contact
• Dry newborn and assess with Apgar score
• Cord traction and fundal massage: optional, only for skilled staff
• Complete partograph
Fourth stage of • Close monitoring of mother’s vital signs every 15 minutes the first hour and every 30 min the
labour/immediate second hour
postnatal period • Close monitoring of newborn according to Apgar (1-5-10 min) and then every 30 min the first 2 hours
• Essential newborn care (vitamin K, TOT. See Module 7). Support immediate breastfeeding.
Continue skin to skin
• Complete documentation of immediate postpartum

3.1. Active phase of first stage of labour
• Should not take longer than 10 hours in multigravidas and 12 hours in
primigravidas. The rule of 1 cm/hour will not be used in uncomplicated normal
labours, but maybe useful as orientation in special deliveries such as breech
and previous C-S
• Amniotic fluid: if membranes are ruptured, the colour of the amniotic fluid
needs to be monitored and recorded (clear, blood stained, or meconium
stained)
Meconium-stained fluid alone is not indicative of foetal distress but requires
closer monitoring: vaginal exam every 2 hours, foetal monitoring at least every
30 minutes and adequate progress of dilatation
• Record all observations in a follow-up sheet for admission
• Allow the client to mobilise, eat and drink lightly and offer alternatives of pain
management. The support during active phase of first stage of labour is crucial
for the client to manage the pain, as well as to collaborate during second stage
• Insert IV line in clients with any risk factor (hypertension, obstetric antecedent,
etc.)

Foetal descent (reminder):
• By abdominal palpation:
– If foetal shoulder >2 fingers above symphysis pubis: presenting part is not
engaged
– If foetal shoulder ≤ 2 fingers above symphysis pubis: presenting part is
engaged
• By vaginal exam:
– If sacral concavity can be reached through vaginal wall (meaning foetal
head is above): presenting part is not engaged
• Foetal station (see Figure 1):
– Relationship of the presenting part (head/buttocks/feet) to the ischial spines
and measured in centimetres above (-) or below (+) the ischial spines
– If the lowest part of the baby’s skull has reached the ischial spines, it can
be taken that the largest diameter of the head (BPD) has passed the pelvic
brim. This is because the distance between the leading edge of the skull and
BPD is smaller than the distance between the spines and the pelvic brim
– Make sure you are assessing the lowest part of the skull bones and not the
caput
– Instrumental delivery can only be attempted when the station is at least 0
(ischial spines)
Figure 1: Foetal station
-3
-2
-1
Spines
+1
+2
+3

3.2. Second stage of labour
• Should not take longer than 2 hours in multiparas and 3 hours in primiparas
• Bladder should be emptied to facilitate foetal passage: encourage client to
urinate and only if unable to urinate (foetal compression) place a single use
catheter with sterile technique
• Vulva and perineum can be rinsed with clean water before delivery
• Always prepare for newborn resuscitation (check material and have an
assistant ready)
If there are no foetal heartbeat abnormalities and labour is progressing well:

– Use the client’s chosen position (kneeling, knees to chest, lying on side or
semi-sitting) and allow birth companion to be present
– Explain and actively communicate all the steps ahead
– Let the client follow their own urge to push and advise on how to push
effectively, and how to breathe and rest between contractions
– When the head starts stretching the perineum: ask the client to pant and
stop pushing as the baby’s head delivers
– Control the birth of the head supporting the perineum and the deflexion of
the head to avoid tears
– Check for nuchal cord and reduce if present
– Exert downward traction to deliver anterior shoulder and accompany
posterior shoulder with perineal support to avoid tears
– Deliver the rest of body and place newborn on the mother’s chest. Quickly
evaluate the newborn’s condition (see Module 7)
– If baby is spontaneously crying, delay cord clamping for 1-3 minutes and
encourage skin to skin with mother (see Module 7)

3.3. Third stage of labour
See also Module 6: Postnatal Care and Postnatal Complications
• Period between delivery of the baby and delivery of the placenta
• Usually takes between 5-15 minutes. Periods above 30-45 minutes will need
active intervention
• In all deliveries perform active management of third stage of labour:
– After the baby is delivered make sure there is no twin and administer 10 IU
oxytocin IM stat (or very slow IV push)
– Cord traction and fundal massage: optional and only indicated for skilled
staff
– After placenta is delivered: inspect placenta and membranes for
completeness
– Revise vaginal canal and perineum to discard any tears
– Gently massage uterus and confirm uterine contraction. Uterus should be
just below the umbilicus and no active bleeding present
• Newborn:
– Delayed cord clamping in all healthy newborns (1-3 minutes) meanwhile
assuring immediate skin to skin contact
– Newborns that cry spontaneously can be dried and assessed with Apgar
score on mother’s chest/abdomen
– Immediate breastfeeding is encouraged (supports uterine contraction)
• Complete partograph and record the time of placental delivery and the
immediate postpartum features

3.4. The use of partograph
• The partograph is a graphical representation of the progression of labour but
also reminds the provider of the observations and examinations to be carried
out during the stages of labour
• It is an extremely useful tool to monitor labour and maternal and foetal
wellbeing, anticipate complications and aid in the decision making for the
management of any abnormality during labour
• It needs to be completed for all clients undergoing labour
• How to fill it in:
– Start the graph when the client has reached 5 cm cervical dilatation and
is having active contractions (3 in 10 min). For inductions of labour the
partograph can be started with 4 cm to have a more detailed follow up
– All above mentioned observations (maternal and foetal) are plotted into the
partograph at the indicated time intervals
• How to interpret it:
– Alert line: crosses from 4 to 10 cm and corresponds to a dilatation speed
of 1 cm/hour. As stated above, 1 cm/hour is an excessively fast dilatation for
some clients without risk factors. However, if the labour curve crosses the
alert line a closer monitoring is advised and a referral to CEmONC should
be considered
– Action line: located 4 hours to the right of the alert line. If the labour
curve crosses this line, a decision needs to be taken (augmentation of
labour, rupture of membranes or C-S) (see Module 4 for prolonged labour
management)

Labour progress chart (partograph) Normal FHR ranges from 110-160
Hospital or health centre:
IP no:
Name: Date of admission: Time of admission:
Age: Gravida: Para:
LMP: EDD: Gestational age:
Risk factors:
PMTCT code: Membranes ruptured at:
200
190
180
170
160
FOETAL 150
HEART 140
RATE 130
120
110
100
90
80
AMNIOTIC FLUID
MOULDING
Consider referral if in a BEmONC centre Refer immediately if not in CEmONC centre or if centre is unable to manage client
10
9
CERVIX
RT ION
ACT
8
(CM)
7 ALE
[PLOT X]
6
5
4
DESCENT
3
OF HEAD
[PLOT O] 2
1
HOURS
TIME
5
PER 10 MINS
CONTRACTIONS
4
3
2
1
Oxytocin U/L
drops/min
DRUGS GIVEN
OR IV FLUIDS
180
170
160
150
140
130
PULSE
120
AND BP
110
100
90
80
70
60
TEMP ºC
PROTEIN
URINE ACETONE
VOLUME
The three main features of the partograph: CONTRACTION KEY

Foetal condition Monitored by: foetal heart rate/membranes and liquor/moulding of foetal skull LESS THAN 20 SECONDS BETWEEN 20-40 SECONDS
Progress of labour Monitored by: cervical dilatation/descent of foetal head/uterine contractions
V1.0
Maternal MSI Reproductive
condition Choices Guidelines for Antenatal
Monitored by: pulse/BP/temperature/urine/drugs/IV care test
fluid/urine MORE THAN 40 SECONDS 3.11
3.5. Foetal monitoring
• Intermittent foetal monitoring is recommended in healthy pregnant clients
that start labour spontaneously: FHR should be checked for at least 1
minute, every 30 min in active first stage of labour and every 5 min in second
stage of labour
• Continuous foetal monitoring: should only be provided in CEmONC setting
and to selected clients with risk factors
Normal foetal monitoring:

• Normal foetal heartbeat is considered 110-160 bpm in term foetuses
• In a pre-term baby, a foetal heart of more than 160 bpm may be normal
• A normal foetal heart rate may slow during contractions but should return to
normal once the uterus is relaxed
Abnormal foetal monitoring:

Signs of foetal distress:
• A foetal heartrate faster than 160 beats/minute (tachycardia) and slower than
110 beats/minute (bradycardia) or an irregular heartbeat
• A very slow heartrate (< 100 bpm) when no contractions are occurring is a sign
of foetal distress
• A rapid foetal heartrate might be in response to maternal fever, hypertension or
amnionitis. If there is a rapid foetal heartrate in the absence of a rapid maternal
heartrate, it has to be considered a sign of foetal distress

Management of abnormal foetal monitoring:
• Insert IV line (in all cases)
• Provide information to the client and birth partner
• Check maternal vital signs, the uterine tonus and the colour of the amniotic
fluid or blood
• Perform a vaginal exam
• If FHR < 100 bpm:
– Stop oxytocin (if there is an infusion running)
– Fully open a plain solution of RL/NS
– Place mother on left lateral and provide oxygen 15 L/min
– If foetal heartbeat does not recover after 5 min, expedite delivery: decide on
either C-S or assisted vaginal delivery (if fully dilated and head engaged).
Prepare for neonatal resuscitation at delivery
– If foetal heartbeat recovers: check every 15 minutes if in first stage of
labour during the next hour and then go back to every 30 minutes until in
second stage
• If > 160 bpm:
– Check for causes of infection and treat
– If fever of unknown origin: treat as for prolonged rupture of membranes and
administer Paracetamol 1 g every 6-8 hours to lower mother’s temperature.
Keep IV maintenance fluids
– If foetal tachycardia persists after decrease of mother´s temperature or the
tachycardia is severe (> 180 bpm): evaluate progress of labour and expedite
delivery

4.0 A
nalgesia During Labour
and Delivery
Analgesia options should be discussed during ANC and the client’s

preferences must be included in the birth plan. During labour, the options
must be offered again and rediscussed if needed
Pain perception during labour varies greatly, with some clients perceiving
it as bearable and others having an extremely distressing experience. The
wish for pain relief and the client’s preference must always be respected, and
all efforts done to fulfil it
The client’s perception of pain during labour should never be judged,
disregarded, or minimised as “physiological”
Pain relief during labour must be actively offered to all clients and provided to
all clients requesting it
Pain management during labour can be non-pharmacological and
pharmacological
4.1. Non-pharmacological pain management

Comfort methods provide pain relief in a natural way during labour.
A combination of some or all of them allows the client to control their
perception of pain
• Vocal Local support: critical component of pain management in labour
and one of the key pillars for the support role of the midwife during labour
• Massage techniques: rubbing the client’s back and hips has shown some
results in relieving pain during contractions. This allows also for an active
role of the birth companion during labour
• Relaxation and breathing techniques: combined with the previous two,
relieves the distress associated with pain and allows the client to control
their perception of pain
• Heat pads, hot bath, or shower: local application of heat to the back or
taking a hot bath/shower relieves contraction pain in some clients
• Deambulation and birth position: deambulation does not only help
labour progress but also helps the client to adopt the most comfortable
position to relieve the pain
This is also critical during second stage of labour: sitting or squatting
positions support adequate progress of second stage of labour but also
relieve the pain and allow for more effective pushes

4.2. Pharmacological pain management
4.2.1. Pethidine 50-100 mg IM PLUS prochlorperazine 3 mg
PO stat dose
• Indication: all clients in active first stage of labour that are not expected
to deliver within 4 hours from the moment of administration (as a guide,
do not administer in primigravidas >=8 cm and multigravidas >=5 cm of
cervical dilatation)
• Secondary effects:
– Drowsiness, fatigue
– Nausea and vomiting (especially if prochlorperazine is not administered
at the same time): can be treated with ondansetron PO or IV 4 mg
8 hourly
– Neonatal respiratory depression
• The risk of neonatal respiratory depression due to opioid effect is linked
to their administration within 2-4 hours of delivery. Outside of this time
frame, it is important to note that most neonatal respiratory depressions
are linked to foetal distress during a second stage of labour and not
with the administration of opioids for pain relief
• Neonatal respiratory depression must be managed as per neonatal
resuscitation flow chart and essential newborn care (see Module 7).
Recent literature review does not recommend the systematic
administration of naloxone to newborns with neonatal respiratory
depression

4.2.2. Alternative options to opioids for mild to moderate
labour pain
Alternative options to opioids have a rather marginal effect on pain relief but
can be offered in cases in which the client is already about to deliver or does
not want to receive opioids
• Paracetamol 1 g IV: can be repeated every 6 hours
• Tramadol 50-100 mg IM: should be administered with prochlorperazine 3
mg PO stat dose to avoid nausea and vomiting. Dosage can be repeated
every 6 hours
• Spinal or caudal block: can be an option in clients that will deliver in
1-2 hours and are experiencing distressing pain that interferes with their
collaboration (especially when an instrumental delivery is a possibility, i.e.
large foetus)
Epidural anaesthesia is currently not contemplated as an option in MSI
obstetric centres due to its requirements in infection prevention, expertise
and equipment, as well as the potential risk of an increase in prolonged
labours and C-S rates

5.0 Respectful Maternity Care
MSI obstetric care aims to provide a safe and respectful experience for
pregnant clients, their partners, and their babies. The care must be client-
centred and minimally invasive, respecting the client’s privacy and dignity, as
well as their wishes in terms of birth companionship, pain management and
birthing position amongst others
As already introduced in Module 1, the birth plan is a key document that
facilitates the discussion and documentation of the client’s wishes and
preferences and allows the provider to explain and prepare the client for the
upcoming labour, delivery and postpartum
Guiding principles of MSI respectful maternity care are:

• All clients followed in ANC will have an agreed and signed birth plan
• The same provider will be visiting a client throughout the pregnancy and
postpartum and whenever possible also during labour and delivery
• At all stages of the process the client’s privacy and dignity will be
safeguarded. The care provided will be guided by compassion and
empathy
• Key actions for this are amongst others:
– Provision of an adequate and private space for labour and delivery
– Staff on duty should be wearing name tags for identification and must
introduce themselves to the client each time a new shift changes during
the client’s admission
– All providers need to explain each step of the process to the client
and the birth partner. All exams and procedures must be explained in
advance and performed in a gentle and respectful way
– A companion of the client’s choice will be allowed during all steps of
the process, including examination. The birth partner will be allowed
to attend the delivery and C-S whenever the client consents (and the
medical conditions allow so)
• Clients giving birth alone should be supported appropriately

• All obstetric care will be guided by a minimally invasive and supportive
spirit:
– Episiotomies are to be avoided. Where an episiotomy is needed, the
provider will document the rationale, provide quality pain management,
and document the procedure up to closure
– Humanised C-S practices must be the norm (see Module 5)
– Ambulation during labour and upright position for delivery will be allowed
where the client wishes
– Midwives are not only a clinical figure, but a key support person who
accompanies the client throughout the whole process (explaining and
providing pain relief, breathing, positioning, etc.)
– Each client will be offered pain management for normal labour, as well as
for any other intervention that requires additional pain management
– The immediate postpartum period will respect the “golden hour of
the neonate”. Skin to skin contact, delayed cord clamping and early
breastfeeding must be the norm in vigorous term babies (including in C-S)

6.0 S
ummary of Dos and Don’ts
During Intrapartum Care
The below table applies for an uneventful uncomplicated normal labour and delivery:
RECOMMENDED NOT RECOMMENDED
• Respectful and minimally invasive maternity care • During (spontaneous) active phase of first stage of labour, a
• Provide an effective and active communication cervical dilatation of < 1 cm/hours is not a routine indication
for an obstetric intervention
• Start partograph at 5 cm of cervical dilatation
• Do not accelerate labour before 5 cm cervical dilatation
• Foetal auscultation with doppler or Pinard is recommended on
(provided foetal and maternal conditions are reassuring)
admission (for at least 1 minute and ideally during and after a
contraction) • Routine clinical pelvimetry on admission is not recommended
for healthy pregnant clients
• Intermittent foetal auscultation (doppler or Pinard) is
recommended every 30 min during first stage of labour and • Routine cardiotocography is not recommended on admission
every 5 minutes during second stage of labour for healthy pregnant clients
• Digital vaginal exam every 4 hours during active phase of first • Continuous cardiotocography is not recommended in healthy
stage of labour pregnant clients during a spontaneous normal labour
• Recommended pain relief during labour for healthy pregnant • Pubic/perineal shaving before vaginal delivery is not
clients: relaxation techniques, manual techniques (massage, recommended
warm packs) and opioids (pethidine) • Administration of enema is not recommended
• Clients without risk factors and normal labour can have an • Denial of pain management for clients in labour is not
intake of oral fluids and light food acceptable
• Encourage a birth position of client’s choice and allow the • Routine vaginal cleansing during labour is not recommended
client to follow their own urge to push • Routine active management of labour to prevent delay is
• AMTSL is recommended in all clients (see Module 6) not recommended (e.g. administer routinely oxytocin or
• Delayed umbilical cord clamping (1-3 minutes after birth) in amniotomy to all primigravidas)
non-compromised newborns and mothers • Administration of antispasmodic agents for prevention of delay
• Skin to skin contact (SSC) immediately after birth (or at least in labour is not recommended
in the first hour of birth) to promote breastfeeding and prevent • Routine episiotomy is not recommended
hypothermia • Application of manual fundal pressure during second stage of
• Immediate breastfeeding including premature and LBW labour is not recommended
newborns that are able to breastfeed • Routine suctioning of newborns with clear amniotic fluid and
• 1 mg vitamin K IM after birth spontaneous birth is not recommended
• Bathing of newborn after 24 hours after birth • Immediate bathing of the newborn is not recommended
• 24 hours facility-based care after delivery • Routine antibiotic for episiotomies are not recommended

7.0 References
• WHO recommendations: intrapartum care for a positive childbirth

experience. Geneva: World Health Organization; 2018. Licence: CC BY-
NC-SA 3.0 IGO
• Managing complications in pregnancy and childbirth: a guide for midwives
and doctors – 2nd ed. Geneva: World Health Organization; 2017. Licence:
CC BY-NC-SA 3.0 IGO
• WHO. Pregnancy, Childbirth, Postpartum and Newborn Care A Guide for
Essential Practice - 3rd ed. Geneva. World Health Organization; 2016.
• WHO recommendations on prevention and treatment of postpartum
haemorrhage http://www.lifewraps.org/wp-content/uploads/2013/03/ WHO-
2013-PPH-highlights.pdf
• WHO The partograph- Preventing prolonged labour, saving mothers and
babies. An e-learning tool https://www.glowm.com/resources/glowm/
videos/safermotherhood/Partograph%20E-tool/Partograph_WHO.swf
• Essential obstetric and newborn care. Geneva: Médecins Sans Frontières;
2019.
• Oxford Handbook of Midwifery (2011 2nd edition). Medforth (et al) Oxford:
Oxford University Press
• Royal College of Obstetricians and Gynaecologists (Great Britain).
Fetal descent. Stations [Internet]. Available from: https://elearning.rcog.
org.uk//easi-resource/maternal-and-fetal-assessment/examination/
station#:~:text=The%20fetal%20station%20is%20the,below%20(%2B)%20
the%20ischial%20spines.
• WHO. WHO recommendation on opioid analgesia for pain relief
during labour [Internet]. 2018 [cited 2020 Oct 5]. Available from: https://
extranet.who.int/rhl/topics/preconception-pregnancy-childbirth-and-
postpartum-care/care-during-childbirth/care-during-labour-1st-stage/who-
recommendation-opioid-analgesia-pain-relief-during-labour
• Moe-Byrne T, Brown JVE, McGuire W. Naloxone for opioid-exposed
newborn infants. Cochrane Database of Systematic Reviews 2018, Issue
10. Art. No.: CD003483. DOI: 10.1002/14651858.CD003483.pub

Module 4
1
Antenatal Complications
Obstetric Care
Module 4: Obstetric Complications
Module contents 7.0 Malpositions and Malpresentations 4.27
7.1. Transverse lie 4.27
1.0 Pre-Labour Rupture of Membranes 4.2
7.2. Breech presentation 4.29
1.1. Definition 4.2
7.3. Face and brow presentation 4.32
1.2. Risk factors 4.2
1.3. Diagnosis 4.2 8.0 Prolapsed Cord 4.34
1.4. Differential diagnosis 4.4 8.1. Definition 4.34
1.5. Risks/complications 4.4 8.2. Risk factors 4.34
1.6. Management 4.5 8.3. Diagnosis 4.34
8.4. Risks/complications 4.34
2.0 Preterm Labour 4.7
8.5. Management 4.35
2.1. Definition 4.7
2.2. Risk factors 4.7 9.0 Hypertensive Disorders During Labour 4.36
2.3. Diagnosis 4.7
10.0 Vaginal Bleeding in Early Pregnancy 4.37
10.1. Definition 4.37
2.5. Prevention of preterm labour 4.9
10.2. Differential diagnosis 4.37
2.6. Management 4.9
3.0 Late-Term and Post-Term Pregnancies 4.12 10.4. Management of abortion 4.40
3.1. Definition 4.12 10.5. Management of ectopic pregnancy 4.41
3.2. Risk factors 4.12 10.6. Management of molar pregnancy 4.43
3.3. Diagnosis 4.12 10.7. Management of other causes of bleeding 4.43
3.4. Risks/complications 4.13 in early pregnancy
3.5. Management 4.13 11.0 Vaginal Bleeding in Late Pregnancy and Labour 4.44
4.0 Intrauterine Foetal Death and Stillbirth 4.14 11.1. Definition 4.44
4.1. Definition 4.14 11.2. Differential diagnosis 4.44
4.2. Risk factors 4.14 11.3. Risk factors 4.46
4.3. Diagnosis 4.15 11.4. Risks/complications 4.46
4.4. Risks/complications 4.16 11.5. General management 4.47
4.5. Management 4.16 11.6. Management of placenta previa 4.48

11.7. Management of uterine rupture 4.49
5.0 Prolonged Labour 4.19 11.8. Management of abruptio placentae 4.50
5.1. Definitions 4.19
5.2. Risk factors 4.19 12.0 Postpartum Haemorrhage 4.51
5.3. Diagnosis 4.20 12.1. Definition 4.51
5.4. Risks/complications 4.20 12.2. Differential diagnosis 4.51
5.5. Management 4.20 12.3. Risk factors 4.53

6.0 Obstructed Labour 4.23 12.5. Prevention 4.54
6.1. Definition 4.23 12.6. Management 4.54
6.2. Risk factors 4.23
6.3. Diagnosis 4.23 13.0 References 4.58

6.5. Management 4.26
1.0 Pre-Labour Rupture of
Membranes
1.1. Definition
• Pre-labour rupture of membranes (PROM): rupture of membranes before
the onset of labour
• Pre-labour preterm rupture of membranes (PPROM): rupture of
membranes before 37 completed weeks of gestation
1.2. Risk factors

• Previous PROM, previous PPROM, or previous preterm labour in
precedent pregnancies
• Infections: UTI, malaria, STI, chorioamniotis
• Multiple pregnancy or any reason for abnormally large uterus (e.g.
polyhydramnios)
• Adolescent mother
• Malnutrition
1.3. Diagnosis
1.3.1. Clinical history:
• Establish time of rupture
• Ask for colour and odour and any accompanying symptoms (e.g.
contractions)
• Check ANC care and previous obstetric history (previous preterm
deliveries, history of recurrent UTI, etc.)
• Confirm gestational age (was there a corrected LMP? What is the EDD?)
• Establish start of contractions, frequency, and intensity
• Ask for symptoms of infection (dysuria, fever, chills, vaginal discharge, etc.)

• Fundal height, foetal presentation, and uterine tenderness
• FHR
• Speculum exam: fluid in the vagina or directly leaking from cervical os
when patient asked to cough. Determine colour and odour
• Digital exam is not routinely indicated to avoid infection. It will only
be performed if contractions are present or an induction is planned.
Any vaginal exam must follow a sterile technique
1.3.3. Laboratory
• Urinary analysis to rule out any UTI that could trigger a premature labour
• Malaria test in endemic context
• Only if available:
– Full blood count with white blood count and differential
– C-reactive protein
– Vaginal and endocervical swabs (microscopy, culture, sensitivity)
1.3.4. Ultrasound
PROM will be diagnosed using the physical exam and clinical history.
Ultrasound can complement the clinical diagnosis especially in PPROM
(preterm) by:
• Confirming foetal presentation and wellbeing
• Foetal growth and estimated foetal weight
• Location of placenta
• Amniotic fluid measurement

1.4. Differential diagnosis
• Leukorrhea: whitish discharge not coming from internal cervical os when
examining with speculum and Valsalva manoeuvre (ask the patient to
cough)
• Expulsion of show: cervical mucous stained with blood rather than
watery discharge
• Urinary incontinence: with speculum exam and Valsalva manoeuvre
(ask the patient to cough), there is no watery leakage coming from
internal cervical os but urine is coming out from urethra or from a fistula
• Intra-amniotic infection (chorioamnionitis):
Diagnosed by a temperature > 38°C and at least 1 of the following
– WBC count > 15,000 cells/mm
– Foetal tachycardia or IUFD
– Tender uterus
– Foul smelling discharge
• Cord prolapse
• Preterm birth in PPROM (<37 weeks GA)

1.6. Management
• Active communication: provide information, manage expectations, and
explain risks
• Admission and monitoring of maternal vital signs, contractions, and foetal
wellbeing
1.6.1. Antibiotic treatment

The following table summarises the type and time of antibiotic needed
depending on GA, signs of infection and labour status
Table 1. Summary of antibiotic indications in PROM
≥37 weeks LMP, PROM>12 hours, Ampicillin IV 2 g single dose followed by 1 g every 4 hours during labour
no signs of infection until delivery
– NO NEED FOR ANTIBIOTICS AFTER DELIVERY
– If client received at least 2 doses (4 hours) apart during labour, the newborn
does not need further treatment
≥37 weeks LMP, PROM<12 hours, Expectant management (monitor and wait for spontaneous labour to start)
no signs of infection
<37 weeks LMP, no signs of Erythromycin PO: 250 mg every 6 hours for 10 days
infection, no labour
<37 weeks LMP, no infection, Ampicillin IV 2 g single dose followed by 1 g every 4 hours during labour until
labour in progress delivery
– NO NEED FOR ANTIBIOTICS AFTER DELIVERY
Presence of infection, regardless Ampicillin IV: 2 g every 8 hours
of GA, labour, or duration of PROM PLUS metronidazole IV: 500 mg every 8 hours
PLUS gentamicin IM or IV: 5 mg/kg once daily
Continue IV administration for 48 hours after fever disappears. Continue with
oral amoxicillin 1 g every 7 hours PLUS metronidazole 500 mg every 8 hours
to complete 7 days of treatment or oral amoxicillin-clavulanic 875/125 mg
every 8 hours for 7 days

1.6.2. Expectant management and induction of labour
The following algorithm summarises the management of PROM depending on GA and signs of infection
Figure 1. Management algorithm for PROM
<24 weeks Counsel client and advise

LMP on termination of pregnancy
Refer to CEmONC with NICU

for premature care
Antibiotics (see table)

No signs of
infection
Dexamethasone IM: 6 mg every
12 hours for 48 hours
24-33+6 Tocolytic agent

PROM weeks LMP
Induction of labour
Signs of
infection
Magnesium sulphate for
neuroprotection in <32 weeks
Antibiotics
No signs of
infection
Expectant management.
Induction at 37 weeks if no
complications
34-36+6
weeks LMP
Signs of
Induction of labour
infection
• Do not administer amoxicillin-clavulanic to preterm pregnant clients as it increases the risk of necrotizing
enterocolitis
• For corticosteroid, MgSO4 and tocolytic regime see chapter of preterm delivery

2.0 Preterm Labour
2.1 Definition
Regular contractions and cervical dilatation in pregnancies < 37 weeks
2.2. Risk factors

There are some risk factors that can influence the appearance of preterm labour:
• Infections: UTI, malaria, STI, chorioamniotis
• PPROM
• Multiple pregnancy or any reason for abnormally large uterus
(e.g. polyhydramnios)
• Adolescent mother
• Malnutrition and pregnancy related pathologies
2.3. Diagnosis
2.3.1. Clinical history:
• Check ANC care and previous obstetric history (history of recurrent UTI, etc.)
• Confirm gestational age (was there a corrected LMP? What is the EDD?)
• Establish start of contractions, frequency, and intensity
• Ask for symptoms of any infection (dysuria, fever, chills, vaginal discharge, etc.)

• Maternal vital signs (BP, pulse, Ta, RR)
• Fundal height, foetal presentation, and uterine status (contractions,
tenderness, etc.)
• Foetal heartbeat
• Speculum exam to rule out PPROM
• Digital exam if cervical os was open on speculum exam
2.3.3. Laboratory
• Urinalysis: midstream culture is recommended
– If not available: microscopy and gram stain and if not available urine dipstick
• Malaria test in endemic countries
• Only if available:
– Full blood count with white blood count and differential
– C-reative protein
– Vaginal and endocervical swabs (microscopy, culture, sensitivity)
2.3.4. Ultrasound
Premature labour is a clinical diagnosis. Ultrasound can complement the clinical
diagnosis by:
• Confirming foetal presentation and wellbeing
• Foetal growth and estimated foetal weight
• Location of placenta
• Amniotic fluid measurement
• Cervical length: with vaginal probe and empty bladder (only for skilled
providers). A cervical length of < 25 mm is indicative of preterm labour

• Postpartum infections and maternal sepsis
• Stillbirth
• Neonatal sepsis
• Prematurity related disorders: respiratory distress, brain injury and cerebral
palsy, necrotizing enterocolitis, etc.
2.5. Prevention of preterm labour

• Preventive measures in antenatal care for identifying and treating infections
(UTI, malaria, STI)
• In patients with risk factors: close monitoring and advise physical rest
2.6. Management
In ALL cases: investigate and treat for infections (UTI, STI, malaria, etc.)
2.6.1. Contraindications and indications to stop labour

Do NOT stop labour and assist delivery if:
• Confirmed >34 weeks GA
• Labour is in active first stage: >5 cm, effaced, regular contractions
• IUFD
• Presence of chorioamnionitis (see PROM)
• Any condition threatening the life of the mother (e.g. eclampsia,
haemorrhage, etc.)
Try to stop labour if:
• None of the above conditions present
• 24-34 weeks GA confirmed

2.6.2. Clinical management
Admission or referral:
• Active communication: inform, clear doubts, counsel on possible outcomes,
manage expectations
• Admission into CEmONC with adequate neonatal care (level II or III according
to MSI classification and depending on gestational age and foetal wellbeing)
• Strict bed rest and adequate hydration (2-3 L/day): advise oral fluids or start IV
Foetal lung maturity:
• Administer corticosteroids in all pregnancies of 24-34 weeks GA that have a
risk to deliver within the next 7 days:
– Dexamethasone IM 6 mg/12 hours for 48 hours OR
– Bethamethasone IM 12 mg/24 hours for 48 hours
• If the preterm labour is stopped but the patient recurs after 7 days of the
corticosteroid course: give an additional single full corticosteroid course
• In diabetic patients: monitor strictly blood glucose while on corticosteroids
Foetal Neuroprotection:
• Administer MgSO4 in all pregnancies <32 weeks at risk of delivering in the
next 24 hours
• MgSO4 will be administered as for eclampsia regime and for 24 hours or until
delivery whichever happens first: IV 4 g over 10–15 minutes, followed by either
IV 1 g/hour for 24 hours, or by IM 5 g every 4 hours
• Secondary effects on the patient are flushing, sweating, nausea, vomiting,
headaches and a rapid heartbeat (palpitations)

Tocolytic treatment:
• Objective: delay delivery for 48 hours to allow improved lung maturity with
corticosteroid treatment
• Nifedipine immediate release tablets 20 mg PO starting dose followed by
10 mg every 4-6 hours
• Do not give nifedipine sublingual due to high risk of drastic placental
hypoperfusion
Reminder: No routine antibiotics are indicated if intact membranes
(see PPROM)
2.6.3. Management of preterm delivery:

In case preterm labour could not be stopped:
• Routine delivery by caesarean section for the purpose of improving preterm
newborn outcomes is NOT recommended, regardless of cephalic or breech
presentation
• Caesarean section should only be indicated for obstetric reasons
• Assisted vaginal delivery with vacuum is NOT recommended in any delivery
<34 weeks
• Labour should be quick to avoid any foetal distress
• Episiotomy may be indicated to accelerate the second stage of labour
• Prepare for a neonatal resuscitation and have a paediatric team ready

3.0 Late-Term and Post-Term
Pregnancies
3.1. Definition
• Post-term pregnancy: pregnancy that extends until or beyond 42 weeks
confirmed GA (≥ 294 days) without spontaneous delivery
• Late-term pregnancy: pregnancy between 41 and 42 weeks confirmed GA
without spontaneous delivery
3.2. Risk factors

• Obesity
• Primigravidas >30 years
• Male foetus
• Previous post-term pregnancy
3.3. Diagnosis
The diagnosis is based on an accurate and confirmed gestational age by LMP
and a first trimester US or in its absence at least an early second trimester US
Please remember: the most frequent cause of post-term pregnancy is

inaccurate dating of pregnancy!
A reminder for accurate dating of pregnancy (see Module 1):

• With first trimester US as first US in the pregnancy: if there is a difference
> 5 days between GA calculated by LMP and GA calculated by US, the
estimated date of delivery should be adjusted as per the first trimester US
• With second trimester US as first US in the pregnancy: if there is a difference
> 10 days between GA calculated by LMP and GA calculated by US, the
estimated date of delivery should be adjusted as per the second trimester US
• When there has been both a first and second trimester US, GA should be
determined by the earliest US

• Stillbirths: the latest evidence shows a gradual increase of stillbirth rates after
39 weeks GA with a sharp rise after 40 and especially after 41 weeks GA
• Neonatal death
• Low Apgar scores, need for resuscitation, neonatal complications
• Perineal trauma, postpartum haemorrhage
3.5. Management
• Clients need to be informed about the pros and cons of expectant
management (higher risk of neonatal adverse events the more days after
41 weeks pass) versus induction of labour
• Induction of labour should be recommended to all pregnancies at 41 weeks
Caesarean section is not routinely indicated for post-term pregnancies, except
for strictly obstetric indications
• If expectant management is chosen by the client, an US and (if available)
a CTG must be performed between 41 and 42 weeks
• Sweeping of membranes can be offered to pregnant clients >39 weeks
(after informed consent)

4.0 I ntrauterine Foetal Death
and Stillbirth
Most stillbirths/IUFDs are 4.1. Definition

preventable with adequate
ANC and labour management A variety of definitions and classifications for foetal demise can be found across
the literature and across different countries
• Intrauterine foetal death (IUFD): foetal death before 28 weeks gestation and
after 14 weeks
• Stillbirth: baby born with no signs of life after 28 weeks of pregnancy
– Stillbirths ante-partum: foetal death diagnosed before start of labour (FHR
negative on admission)
– Stillbirths intra-partum: foetal death diagnosed after start of labour (mostly
FHR positive on admission)
Almost half of all stillbirths happen when the client is in labour. Intra-partum
stillbirths are preventable by adequate intrapartum care
Ante-partum stillbirths and IUFDs can partly be prevented by an adequate
antenatal care (11% due to syphilis and almost 20% due to malaria in
endemic areas)
4.2. Risk factors

• Post-term pregnancy
• Maternal infections in pregnancy (malaria, syphilis and HIV)
• Maternal disorders (especially hypertension, obesity and diabetes)
• Foetal growth restriction
• Congenital abnormalities
• Cord accident

4.3. Diagnosis
Clients may present with following signs and symptoms:
• Absence of foetal movements
• Cessation of symptoms of pregnancy (e.g. breast engorgement)
• Decrease of symphysis-fundal height
• Uterine size decreases or small fundal height for GA
4.3.2. Ultrasound
FHR can be checked with Pinard or Doppler, however the diagnosis of IUFD or
stillbirth must be confirmed by US. It is always advisable to ask a colleague to
verify the diagnosis
Common US findings are:
• Absence of foetal heart activity
• Secondary features: abnormal foetal head shape, reduced or absent amniotic
fluid, hydrops or maceration, intra-foetal gas collections, etc.
It is not uncommon that a client presents with passive foetal movements after a
diagnosis of IUFD/stillbirth. If this is the case it is always advisable to repeat the
US and reassure and counsel the client.
4.3.3. Laboratory
If available, the following tests are recommended:
• Full blood count with white blood cells, platelets
• Coagulation
• Malaria and syphilis testing
• Urinalysis

• Disseminated intravascular coagulopathy (DIC): DIC may occur in up to 10%
of pregnancies after 4 weeks of the occurrence of an intrauterine foetal death
• Chorioamnionitis
4.5. Management
4.5.1. General recommendations
• Spontaneous delivery usually occurs between 15-20 days after intrauterine
foetal death. However due to the risk of developing DIC as well as the
probability of subclinical intrauterine infection, induction of labour is
recommended to ALL clients presenting with IUFD/stillbirth
• Caesarean section should be avoided. Elective CS are only admittable in case
of complete placenta praevia, severe antepartum haemorrhage or transverse
lie that cannot be externally rotated
4.5.2. Induction of labour (see obstetric procedures)

• If favourable cervix (Bishop score ≥6): rupture of membranes and oxytocin
perfusion
If there is a previous uterine scar or any other condition in risk of uterine
rupture, half the dosage of oxytocin (see Module 5)
• If non-favourable cervix (Bishop score <6): misoprostol induction as per table
below

Table 2. Induction of labour for IUFD
INDUCTION OF LABOUR WITH INTRAUTERINE FOETAL DEATH IN PATIENTS WITH NON-FAVOURABLE CERVIX
TO ALL PREGNANCIES (regardless of GA): mifepristone PO 200 mg single dose PLUS 48 hours later misoprostol as per below
13-26 weeks 27-33 weeks ≥34 weeks
Misoprostol 200 mcg sublingually/ Misoprostol 100 mcg sublingually/ Misoprostol 25 mcg intravaginally
vaginally/buccal, every 4 to 6 hours until intravaginally/buccal every 4-6 hours every 6 hours OR 25 mcg PO every
labour or max of 5 doses until labour or max of 5 doses 2 hours, to be repeated if necessary,
the following day until start of labour or
max of 5 doses
- Buccal route means holding the tablets against the cheek for 30 minutes and then swallowing the remnants
- If only 200 mg tablets are available: smaller dosages can be achieved by crushing and dissolving 1 tablet in 200 ml clean
water: 1 mcg per 1 ml. Labelled solution to be kept (well labelled) only for 24 hours
- A maximum of 5 doses is recommended
- In case of previous uterine scar (C-S) or risk of uterine rupture (any abnormally large uterus, e.g. twin pregnancy): HALF THE
DOSAGE OF MISOPROSTOL
- In previous uterine scar (C-S) and ≥34 weeks: administer mifepristone and consider ripening of cervix with Foley catheter 24-
48 hours later
4.5.3. Delivery
• Labour can be allowed to be slower than normal (pass the action line) and the
second stage can be supported by any possible means
• It is frequent that the placenta is more attached to the uterine wall than in live
pregnancies:
– Extra careful revision of placenta and membranes is required
– If delayed third stage of labour: manual removal of placenta and manual
revision of uterine cavity
• Monitor any excessive bleeding that could be a sign of DIC

4.5.4. Postnatal care
• Suppression of lactation: carbergoline 1 mg oral on first day (D1)
followed by 0.25 mg every 12 hours for the next 2 days (D2, D3)
• Psychological support should be offered to all clients (and families)
experiencing a foetal loss. The risk of postpartum depression is higher
than in live births and needs close monitoring
• There is some evidence that seeing and holding the baby after delivery helps
the process of grief. However, clients should be offered the possibility to see
and hold their baby without insisting or coercing them

5.0 Prolonged Labour
5.1. Definitions
• Prolonged labour: applies only after entering the active phase of
labour (> 5 cm). No progress in cervical dilatation after 4 hours with regular
contractions (3 contractions in 10 min lasting at least 40 sec) OR no progress
in foetal descent in complete dilatation for 3 hours in primigravidas and 2 hours
in multigravidas
• Prolonged latent phase of labour: regular contractions without reaching
5 cm of dilatation for more than 12 hours
• False labour: retrospective diagnosis after a client starts with contraction in
latent phase (< 5 cm cervical dilatation) but does not progress to active stage
of labour as contractions cease
5.2. Risk factors

Prolonged labour can be due to the “four Ps”:
• Power: inadequate contractions or ineffective maternal pushing efforts
• Passage: pelvis too small (cephalopelvic disproportion)
• Passenger: foetus too big for the pelvis or in a malposition (cephalopelvic
disproportion)
• Psyche: maternal anxiety or distress due to pain can prevent progress of
labour
Some risk factors can be:
• Adolescents
• Primigravidas
• Diabetic mother (macrosomic foetus)
• Obesity
• Previous prolonged or obstructed labour (previous C-S, previous instrumental
delivery, etc.)

5.3. Diagnosis
Prolonged labour can only be diagnosed with a partograph
• If the patient arrives with a history of prolonged labour, be careful in assessing:
– PROM
– Time of start of regular contractions
– Any medications provided at home or another facility before arrival
(e.g. oxytocin, misoprostol, etc.)
– FHR
– Contractions: regularity and frequency, appropriate uterine relaxation
between contractions
– Shape of uterus (discard uterine rupture or pre-rupture)
• Obstructed labour (see below)
• Foetal distress
5.5. Management
The management of prolonged labour in the first and second stage is
represented in the below flowcharts
• Obstruction and/or cephalopelvic distortion (CPD) needs to be excluded before
proceeding with the management
• Partograph needs to be used in all cases

Figure 4. Management of no progress during active first stage of labour
No progress in cervical dilatation for 4 hours during ACTIVE FIRST

STAGE (no obvious CPD, normal FHR)
(3 contractions every 10 minutes, Inadequate uterine

each lasting 40 seconds) contractions
Membranes Membranes Membranes Membranes

intact ruptured intact ruptured
Rupture Rupture
membranes Reassess CPD, membranes and Augment with
and reassess possible C-S (slowly) augment oxytocin
in 2-4 hours with oxytocin
Reassess in 2-4
hours
If progress:
continue labour
If no progress: C-S

Figure 5. Management of no progress during second stage of labour
No foetal engagement or descent after fully dilatation 3 hours

in primigravida and 2 hours in multigravida
Foetal head is engaged (at least 2/5 Foetal head is NOT engaged (above
from symphysis pubis or station 0 by 2/5 from symphysis pubis or higher
vaginal exam) than station 0 by vaginal exam)
Adequate Inadequate Assess for CPD, malposition

uterine uterine
contractions contractions
Augment with If CPD or If no CPD: allow one

oxytocin malposition more hour and empty
incompatible with bladder, change client’s
vaginal delivery: position to allow for
C-S internal rotation of
presenting part. If
Empty bladder
inadequate uterine
Instrumental delivery with vacuum contractions: augment
+/- episiotomy with oxytocin
Engagement: No engagement: C-S

vaccuum delivery

6.0 Obstructed Labour
6.1. Definition
Obstructed labour: arrest of vaginal delivery due to a mechanical obstruction
(passage-passenger) despite regular and adequate contractions for more than
24 hours
6.2. Risk factors

• Same as prolonged labour
• Obstructed labour is one of the possible complications of prolonged labour
and constitutes an obstetric emergency
• CPD including malpresentations and malpositions are the most frequent
causes
6.3. Diagnosis
6.3.1. Clinical history
The patient normally arrives with a history of prolonged labour for more than
24 hours
The clinical history needs to address:
• Previous obstetric and general history
• Presence and time of PROM
• Start of contractions and evolution
• Any medication administered to the client during labour

Figure 3. Uterine pre-rupture. 6.3.2. Physical examination
Bandl’s ring
General exam:
Shape of the abdomen
in obstructed labour • Patient is anxious, agitated or completely exhausted
Bandl’s ring
Retracted upper Distended lower • Signs of dehydration (dry mucous membranes, ketonuria) and possible
uterine segment uterine segment hypovolemic shock (low BP, tachycardia)
• Possible fever due to chorioamnionitis
• Distended bladder due to impossibility to empty bladder as presenting part is
obstructing the urethra
• Uterus:
– Imminent uterine rupture with Bandl’s retraction ring (uterus with hourglass
shape)
– Strong contractions are frequent but it is also possible that the client already
presents with no contractions due to uterine exhaustion
– Uterine rupture: foetal parts are palpable through abdominal wall, mother is
in shock
Vaginal exam:
• Oedema of cervix and sometimes vulva and vagina
• If cephalic presentation: presenting part is not engaged, but there is an intense
caput and moulding
• If transverse presentation: shoulder can be impacted by pelvic brim or a hand
prolapse present
• Foul-smelling discharge in cases of chorioamnionitis

6.3.3. Laboratory
No additional laboratory tests are required as the diagnose is clinical.
However, for the management and prevention of possible complications it is
recommended to ask for:
• Blood grouping and cross matching: ensure donor/blood availability
• Complete full blood count or at least Hb
• Urinary test: ketonuria is frequent but not diagnostic
6.3.4. Foetal status

• Doppler/Pinard: FHR may show foetal distress or even foetal death
• Ultrasound: the diagnosis of obstructed labour is clinical, however US can
confirm a foetal death or a complicated presentation
• Uterine rupture
• Foetal distress or foetal death
• Postpartum haemorrhage
• Intrauterine infection, maternal sepsis
• Obstetric fistula
• Maternal and neonatal mortality

6.5. Management
6.5.1. General management
• Insert 16-18 G IV line and start immediate fluid resuscitation with RL or NS
(80-160 dpm)
• Insert Foley catheter
• Start antibiotics
Ampicillin IV 2 g every 8 hours PLUS metronidazole IV 500 mg every 8 hours

PLUS gentamicin IM/IV 5 mg/kg once daily
Continue IV administration for 24 hours if no fever or in case of fever until 48

hours after fever disappears
Continue with amoxicillin 1 g every 8 hours PLUS metronidazole 500 mg

every 8 hours PO to complete 7 days of treatment or amoxicillin-clavulanic
875/125 every 8 hours for 7 days
6.5.2. Mode of delivery

• If foetus is alive: perform an immediate C-S
• If foetus is dead: assess possibility of vaginal delivery or destructive delivery.
If not possible or acceptable perform C-S
• In case of uterine rupture: see module on uterine rupture
6.5.3. Postpartum period:

• The risk of uterine atony and postpartum haemorrhage is extremely high
• To prevent obstetric fistula, leave Foley catheter for 14 days and encourage
the intake of 4-5 L fluids. If after the removal of the catheter there is a fistula
(hole in the anterior vaginal wall), refer for specialist care

7.0 Malpositions and
Malpresentations
7.1. Transverse lie

7.1.1. Definition:
Foetus lies transverse across the uterus with head on one side and buttocks
on the other. The lie can be dorso-inferior (with the back downwards) or
dorso‑superior (with the back upwards)
Figure 4 7.1.2. Risk factors

• Grand multiparity (<5 previous deliveries)
• Polyhidramnios
• Uterine malformations
• Preterm
• Placenta praevia
• Twin pregnancy
7.1.3. Diagnosis
A transverse lie should be diagnosed during antenatal care. Unfrequently it may
be diagnosed during labour in clients with deficient ANC follow up or in clients
with unstable presentations (such as in grand multiparas or polyhydramnios)
The signs and symptoms are:
• Uterus is smaller than gestational age but enlarged on the sides
• Cephalic and breech pole can be palpated on each side of the uterus
• If cervix is dilated: on vaginal exam a shoulder, hand or arm can be felt.
Frequently there is a cord prolapse. Sometimes on vaginal exam there is no
presenting part felt
• Ultrasound: will confirm clinical diagnosis

7.1.4. Complications/risks
• Cord prolapse
• Obstructed labour
• Uterine rupture
• Maternal and perinatal mortality
7.1.5. Management
• During antenatal care:
– Assess possibility of external version
– If external version is not possible or unsuccessful: schedule C-S at around
38-39 confirmed weeks GA
• During labour:
– If fully dilated: assess possibility of internal version and total breech
extraction. If it is a twin pregnancy, this option is only possible if the
foetus in transverse line is the second twin
– For all other cases: Caesarean-section
– In cases of foetal death: insist on the possibility of internal version or
destructive delivery before performing a C-S (see Module 5)

7.2. Breech presentation:
7.2.1. Definition
Longitudinal lie being the presenting part the buttocks of the foetus
• Complete breech: flexion at hip and knees
• Frank breech: flexion at hip and extension at knees
• Footling presentation: extension at hip and knees of one or both limbs
• Knee presentation: extension at hip and flexion at knees of one or both limbs
Figure 5. Breech presentations
Complete breech Frank breech Footling breech

7.2.2. Risk factors
• Uterine abnormalities (e.g. uterine fibroids or bicornuate uterus)
• Grand multipara
• Placenta previa
• Oligo or polyhydramnios
• Twin pregnancy
• Congenital anomalies (e.g. hydrocephalus, meningomyelocele)
• Preterm
7.2.3. Diagnosis
• Clinical history: client may refer to foetal kicks in lower abdomen and against
the bladder and a round and hard part under the rips
• Physical exam:
– Uterine exam: cephalic pole (round, hard and mobile) can be felt at
the uterine fundus. The inferior pole is bigger, irregular, less hard, and
less mobile
– Vaginal exam during labour: soft presenting part (buttocks) or feet/knees
• Ultrasound: will confirm diagnosis
• Prolonged and obstructed labour
• Cord prolapse
• Foot prolapse
• Perineal tears
• Newborn birth injuries
• Foetal distress, perinatal mortality

7.2.5. Management
During antenatal care:
• Inform patient and prepare for delivery in a CEmONC
• Assess possibility of external version (see Module 5)
• Breech presentation with no other additional factors is not an indication for
programmed C-S
During labour:
• Insert IV line
• Use partograph
• Monitor dilatation more frequently (2-4 hours)
• Do not rupture membranes. If contractions are inadequate, augment with
oxytocin
• If membranes rupture: perform vaginal exam immediately to assess for cord
prolapse
• Presence of meconium is frequent in breech presentations and is not indicative
of foetal distress
Delivery: see obstetric procedures
Vacuum extraction is contraindicated

Figure 6 7.3. Face and brow presentation
Face chin anterior 7.3.1. Definition:
• Brow presentation: foetus is presenting brow, orbits and anterior fontanelle.
Eyes and partially the nose can be sometimes palpated through vaginal exam
but not the chin
Brow presentation is an absolute CPD and vaginal delivery is NOT possible
• Face presentation: the presenting part is the foetal face. Eyes, nose, mouth,
and chin can be palpated through vaginal exam
– Chin-anterior face presentation: chin is pointing anteriorly (towards the
symphysis pubis). Vaginal birth is possible
– Chin-posterior face presentation: chin is pointing posteriorly (towards the
rectum). This is an absolute CPD and vaginal delivery is NOT possible
7.3.2. Risk factors

• Multigravidas
• Uterine malformations
Face chin posterior
7.3.3. Diagnosis
Diagnosis is made clinically through vaginal exam during labour. Antenatal
diagnosis with US is infrequent and not reliable as the foetal position can change
until labour starts

• Foetal distress
• Perineal tears
• Prolonged and obstructed labour
7.3.5. Management
• Chin posterior: C-S
• Chin-anterior: normal vaginal delivery. Episiotomy may be required (special
care required not to hurt face while cutting)
• Brow: sometimes it is possible to extend the presentation by grabbing the
chin through vaginal exam and converting the brow presentation into a face
presentation. If this is not possible, deliver by C-S

8.0 Prolapsed Cord
8.1. Definition
Situation in which the umbilical cord drops in front of the presenting part when
membranes rupture
Cord presentation: when the umbilical cord is felt on vaginal exam in front of
the presenting part, but membranes are intact
8.2. Risk factors

• Breech presentation, especially in footling presentation
• Transverse lie
• Twin pregnancy
• Polyhydramnios
• Sudden rupture of membranes or artificial rupture of membranes with high
presenting part
• Prematurity
8.3. Diagnosis
• Cord can be felt on vaginal exam when membranes rupture. If foetus is alive
the cord will be pulsating
• If the foetus is alive, foetal distress is very frequent as the cord is compressed
by the presenting part
• Foetal distress, neonatal distress, and death
• Foetal death

8.5. Management
A cord prolapse with alive foetus is an obstetric emergency in which the delivery
needs to be immediately expedited
8.5.1. If the foetus is dead

No specific intervention is required, proceed for a vaginal delivery as for a
stillbirth
Figure 7: Knee chest position 8.5.2. If the foetus is alive

• Call for help and ask to prepare for an emergency C-S (or an emergency
transfer to a CEmONC)
• Place the client into a deep knee chest position (see Figure 7) with the head
downwards or a deep Trendelenburg position (head down, legs up) in order to
decompress the cord
• Manually push the presenting part upwards through vaginal exam and do not
stop pushing until foetus is extracted by C-S
• This manoeuvre can be complemented by placing the other hand on the
suprapubic region to help keeping the presenting part out of the pelvis.
Otherwise to maintain the suprapubic pressure, the bladder can be filled with
500-750 ml of NS and the Foley catheter clamped until C-S is performed
• Perform an emergency C-S
• In cases in which the patient is in a second stage of labour with presenting part
engaged: expedite delivery with vacuum extraction

9.0 Hypertensive Disorders
During Labour
The diagnosis and management of pregnant clients with hypertensive disorders

is detailed in Module 2

10.0 Vaginal Bleeding in
Early Pregnancy
10.1. Definition
Vaginal bleeding in pregnant clients ≤ 22 weeks GA

Bleeding in the first half of pregnancy can have different causes:
• Abortion: threatened, incomplete, complete or septic abortion
• Ectopic pregnancy: extra uterine pregnancy that can be tubal, cervical or
abdominal
• Molar pregnancy: abnormal form of intrauterine pregnancy in which only
trophoblastic tissue (placenta) grows inside the uterus
• Other conditions: cervicitis (inflammation of the cervix), functional bleeding
(light bleeding associated with implantation of pregnancy in uterus)

Table 3. Differential diagnosis of vaginal bleeding in early pregnancy
Signs and symptoms US
Threatened - Light bleeding, no expulsion of products Viable intrauterine pregnancy

abortion - Light abdominal cramps
- Closed cervix
- Uterus size corresponds to GA
Complete - Light bleeding after history of heavy bleeding with Empty uterus with thin endometrial layer visible
abortion expulsion of clots or products of conception
- Light abdominal cramps after history of painful
cramping
- Closed cervix
- Uterus much smaller than GA
Incomplete - Moderate or heavy bleeding with expulsion of Uterine cavity with products of conception or clots
abortion products of conception
- Painful abdominal cramps
- Cervix open
- Uterus smaller than GA
Missed - Light bleeding, no expulsion of products • Intrauterine pregnancy
abortion - Light abdominal cramps • Embryonic cardiac activity
- Closed cervix • Embryo > 6 mm without cardiac activity
- Uterus size smaller than GA OR
• Gestational sac > 20 mm without embryonic pole or yolk
sac
OR
• A follow up scan after at least one week shows still no
embryonic cardiac activity or the gestational sac remains
empty
Septic Same as incomplete PLUS Same as incomplete PLUS
abortion - Foul-smelling discharge • Possible adnexal or pelvic abscess
- Painful uterus and abdominal palpation, signs of • Hyperechoic endometrial layer
peritonitis • Abdominal abscesses or free fluid
- High fever, septic shock
- History of unsafe abortion
Ectopic - Light bleeding • Empty uterus (image of pseudo gestational sac is
pregnancy - Lower abdominal pain usually in one of iliac fosses possible)
- Uterus much smaller than GA (almost non pregnant) • Ectopic pregnancy visible or at least adnexal mass
- Cervix closed • Free fluid in Douglas pouch or frank hemoperitoneum
- Signs of peritonitis
- Signs of anaemia: paleness, fatigue,
unconsciousness, hypovolemic shock
Molar - Heavy or light bleeding, sometimes partial expulsion • No evidence of embryo/foetus, vesicula placenta is
pregnancy of products that resemble grapes invading the whole uterine cavity
- Cervix closed or open • Typical US image of “snowstorm”
- Abdominal cramps • Theca-lutein ovarian cysts
- Uterus bigger than GA and soft on palpation
- History of severe nausea/vomiting
Cervicitis - Light bleeding Normal intrauterine pregnancy
- Uterine size same as GA
- Cervix closed
- On speculum: ectropion or cervical surface bleeding
Functional Same as threatened abortion but without abdominal Normal intrauterine pregnancy, ovarian functional cyst
uterine cramps (corpus luteum)
bleeding

• Hypovolemic or septic shock in septic abortion, severe bleeding incomplete
abortion or ectopic pregnancy
• PID and chronic sequalae of septic abortion such as infertility
• Maternal death

10.4. Management of abortion
The management of the different types of abortions is described in Table 4
Table 4. Management of different types of abortion
Threatened Physical rest and follow up in 7-10 days

abortion
Incomplete In case of severe bleeding:
abortion - BP, heart rate and monitor bleeding
- IV line (16-18 G) and fluid resuscitation with RL or NS
- Hb, blood group, cross match and ensure blood availability
- Pain management
<13 weeks GA:

- MVA if acute bleeding OR
- Misoprostol 400 mcg sublingually or 600 mcg PO single dose
13-22 weeks GA:

- MVA if acute bleeding OR
- Misoprostol 400 mcg sublingually every 3 hours until expulsion. If no expulsion after 12 hours: consider D&C
- In >16 weeks: oxytocin infusion (40 IU in 1 L IV fluid at 40 drops/min) can be an alternative to misoprostol
- After MVA or D&C in acute bleeding: administer 800 mcg misoprostol rectally after the intervention
Septic - Examine for foreign objects in vaginal, cervix or uterus
abortion - Examine for injuries in vagina, cervix or uterus
- MVA or D&C as soon as possible irrespective of gestational age
- Ampicillin IV 2 g every 8 hours PLUS metronidazole IV 500 mg every 8 hours PLUS gentamicin IM/IV 5 mg/
kg once daily OR amoxicillin-clavulanic acid 875/125 mg every 8 hours IV PLUS gentamicin IV/IM 5 mg/kg
once daily
- Continue IV at least 48 hours or until fever disappears then change to oral: amoxicillin-clavulanic acid 875/125 mg
every 8 hours for 5 days OR amoxicillin 1 g every 8 hours PLUS metronidazole 500 mg every 8 hours for 5 days
- TT vaccine when no previous TT in the last 5 years or unknown vaccination status
Missed <13 weeks: misoprostol 600 mcg sublingually OR 800 mcg vaginally (posterior fornix) every 3 hours until cramping
abortion and expulsion starts (max 3 doses) OR direct MVA
>13 weeks: mifepristone PO 200 mg single dose PLUS 48 hours later misoprostol 200 mcg sublingually/vaginally/
buccal every 4 to 6 hours until labour or max of 5 doses
In all cases Counsel for postabortion contraception

10.5. Management of ectopic pregnancy
Must be handled in a CEmONC
10.5.1. Surgical management

• IV line, blood group and cross matching and prepare for blood for transfusion
• Immediate laparotomy is indicated in ruptured ectopic pregnancies. Non-
ruptured ectopic pregnancies can be scheduled for laparotomy but without
major delay (same day as diagnosis and under admission and close
monitoring)
• For tubal ectopic pregnancies: unilateral salpingectomy is indicated
Salpingostomies have been described as a surgical option in early
diagnosed non-ruptured tubal pregnancies. However, evidence shows that
the postoperative functionality of the sutured tubes is compromised with an
increased risk of subsequent ectopic pregnancy and infertility

10.5.2. Expectant management
• Indications:
– Adnexal mass < 20 mm
– Serum hCG < 1000 IU/L AND declining progressively
– Asymptomatic patients
– Absence of hemoperitoneum
– No sign of rupture or intraperitoneal bleeding
– No foetal parts
– Client is informed about long recovery (at least 4-6 weeks), the need of
frequent follow ups and the possibility of a failure of treatment (around 7-10%
progress or rupture)
• Follow up with twice weekly serum hCG and scan once a week. There must
be a trend of falling serum hCG and a decrease in size of adnexal mass in the
US. Follow up until serum hCG is less than 10 IU/L
• The risk of rupture in a patient with an ectopic pregnancy exists until the hCG
level has fallen to less than 10 IU/L
• Medical management with methotrexate: not recommended in MSI centres
due to the specificities of the drug
• Cervical ectopic pregnancies can be mistaken for an incomplete abortion.
Once diagnosed immediate surgical treatment is indicated (surgical resection
through cervical cone)
• Abdominal ectopic pregnancies are rare but after being diagnosed they
need a laparotomy with removal of embryo/foetus. Sometimes placenta
will need to be left in the abdominal cavity if firmly attached to bowels or
mesenterium
In all cases: counsel for contraception after resolution of the ectopic pregnancy

10.6. Management of molar pregnancy
Needs to be handled in CEmONC and sometimes requires referral to a tertiary
specialised facility
• IV line, close monitoring, blood grouping and cross matching. Prepare for
blood for transfusion
• MVA or D&C guided with US to assure uterine vacuity and under oxytocin
infusion (20 IU in 1L at 160 drops/min). Both procedures have a high risk of
perforation and need an experienced provider
• In molar pregnancies >18-20 weeks, multigravidas and/or severe bleeding:
subtotal hysterectomy must be considered
• Up to 15% of molar pregnancies can persist or degenerate to a
choriocarcinoma:
– 2 weeks after evacuation: follow up with US
– 6-8 weeks after evacuation and then on monthly basis up to 1 year:
Follow up with serum hCG
– If hCG turns positive: discard pregnancy and refer for possible
chemotherapy to higher level
– Provide contraception for at least 1 year after evacuation
10.7. Management of other causes of bleeding

in early pregnancy
10.7.1. Cervicitis
• Examine cervix and if available: Papanicolaou, endocervical swab and
HPV test
• If not available: give presumptive treatment for gonorrhoea and chlamydia
and re-examine in 3 months
10.7.2. Functional bleeding

Does not require any management other than informing the patient

11.0 Vaginal Bleeding in Late
Pregnancy and Labour
11.1. Definition
Vaginal bleeding presenting in pregnant clients > 22 weeks GA or during labour

• Placenta previa: abnormal implantation of placenta at or near the cervical
os. Can be complete (covering completely internal cervical os), partial
(covering partly internal cervical os) or marginal (in the limit of cervical os
without covering it)
• Abruptio placentae: separation of a normally implanted placenta before foetal
birth. Can be complete (all the placenta is separated) or partial (haematoma
has built up beneath the placenta)
• Uterine rupture: rupture in the uterine wall usually occurring during labour
• Show: blood stained mucus that precedes the onset of labour in some clients

Table 5. Differential diagnosis of antepartum haemorrhage
Signs and symptoms Ultrasound
Placenta previa Typically: painless bleeding • Placenta occupying partly or completely the
• Moderate to severe bleeding, usually described internal cervical os
as red “fresh” blood • Variable foetal presentation
• Relaxed uterus, no abdominal pain
• Foetal presentation is high
• Foetal condition is good until mother’s condition
is compromised
• Maternal shock may occur if acute or prolonged
bleeding
Abruptio placenta Typically: intermittent/constant pain with • Abruptio placenta is sometimes not visible
moderate dark bleeding by US, especially when a retained small
• Light to severe bleeding, usually described as retroplacental haematoma starts
dark “old” blood • If visible: retroplacental haematoma. Blood and
• Maternal shock out of proportion to the amount clots in amniotic fluid. Foetal distress or IUFD
of blood seen vaginally: vaginal bleeding
may not reflect the real amount of blood loss
that the client is suffering as a retroplacental
haematoma can retain a considerable amount
of blood
• Sudden severe abdominal pain, constant or
intermittent
• Uterus contracted/tender/tense
• Foetal distress or IUFD frequent
• If membranes rupture: fluid tainted with blood
Uterine rupture Typically: severe abdominal pain with • Diagnosis should be clinical rather than by US
moderate bleeding • Dead foetus in abdominal cavity
• Vaginal bleeding is light to moderate • Free fluid
• Presence of maternal shock • Uterus may be contracted or in strange shape
• Severe abdominal pain and distension due to behind or in front of intra-abdominal foetus
abdominal haemorrhage
• If uterine rupture has already occurred patient
may refer to history of acute pain that has
subsided
• Difficult to palpate the uterus but foetal parts
may be easily palpable through abdominal wall
• IUFD
• Maternal shock
• Uterine rupture may be diagnosed during
postpartum period, presenting as PPH (see
PPH)
Show • Mucous mixed with small amount of blood Normal
• Irregular contractions typical from a latent phase
of labour
• Foetal and maternal wellbeing

11.3. Risk factors
• Placenta previa: multigravidas, previous C-S
• Abruptio placenta: previous abruptio in other pregnancy, abdominal trauma,
hypertensive disorders in pregnancy, toxics (cocaine, tobacco)
• Uterine rupture: previous C-S or other uterine scars, prolonged and
obstructed labour, CPD
• Maternal shock
• Maternal and foetal mortality
• DIC in abruptio cases
• Placenta accreta in cases of placenta previa and previous uterine scar

11.5. General management
• Urgently call for help and mobilise all available personnel. Client may quickly
get into hypovolemic shock as condition can deteriorate quickly
• Always arrange for immediate transfer to CEmONC (stabilising in the
meantime)
• Maintain Airway, Breathing and Circulation
• Take pulse, BP, RR and Ta. Monitor every 15-30 min
• 2 IV lines (16-18 G), start RL or NS
• Foley catheter
• Take Hb, crossmatching, prepare for transfusion
11.5.1. Management of shock

• 1 L NS or RL to pass in 15-20 minutes. Do not use plasma substitutes
(Dextran). Second 1 L to pass in 40 minutes. THEN 2-3 x the volume the
patient is calculated to be losing
• Elevate legs of patient to increase venous return
• Cover patient to maintain heat
• Oxygen 6-8 L/min by mask of nasal cannula
• Start transfusion and manage underlying cause

11.6. Management of placenta previa
• All clients with placenta previa require management in a CEmONC
• The management of a complete placenta previa will depend on the severity of
the bleeding and the GA in weeks but in all cases will require C-S
• In a partial and marginal placenta previa that presents with light bleeding and
spontaneous labour, amniotomy could be performed to allow the foetal head
to descent and compress the bleeding placental vessels. If the bleeding stops,
the labour evolves quickly and there is no maternal neither foetal distress,
a vaginal delivery under strict monitoring can be attempted
Table 6. Management of complete placenta previa
Management of complete placenta previa
Continuous heavy bleeding • Immediate C-S

or severe acute bleeding • Be aware of associated risk of placenta accreta
(independent of GA or foetus when placenta praevia is associated to previous
alive or dead) uterine scar
Light to moderate bleeding in • Keep the client in the hospital until delivery under
alive and premature foetus strict bed rest
• Administer steroids for maturing foetal lungs (see
premature labour)
• Prolong the pregnancy until 34 weeks or at least
until complete cycle of steroids has been given
• Blood and theatre must always be prepared in
case of acute bleeding
Light to moderate bleeding with • C-S
IUFD or stillbirth (independent • Be aware of the risk of placenta accreta when
of GA) placenta praevia is associated to previous
uterine scar
Light to moderate bleeding in • C-S
alive and at term foetus • Be aware of the risk of placenta accreta when
placenta praevia is associated to previous
uterine scar

11.7. Management of uterine rupture
• All clients with uterine rupture require management in a CEmONC with
experienced surgical capacity
• Stabilise the patient as per general management and prepare for immediate
laparotomy
• The surgical procedure of choice needs to be the fastest possible as the
patient is usually in an unstable condition
• In all cases, special attention is needed in revising the integrity of adjacent
structures such as bladder, cervix and vagina, ureters, and bowels
• In impending ruptures (Bandl’s ring visible and violent abdominal pain in the
context of prolonged or obstructed labours) a vaginal delivery is possible if
the foetal head is engaged (at least station 0) and a vacuum can be applied to
rapidly deliver the baby. In these cases, a manual exploration of uterine cavity
needs to be undertaken to rule out rupture
11.7.1. Repair of uterine rupture

• Indications
– Tear is limited and visible
– No signs of infection (uterine rupture < 12 hours)
– No devitalized or bruised borders of tear
• Notes
– The client and family must be counselled on and advised to undergo a
bilateral tubal ligation, as the risk of another uterine rupture in subsequent
pregnancies is extremely high
– Always prepare for possible PPH due to frequent uterine atony
11.7.2. Hysterectomy
• Indications:
– Uterine rupture has happened >12 hours or presents sings of infection
– Uterine tear is extensive, not completely visible or there are multiple tears
– Borders of tear present severe bruises, hematoma or devitalized tissue that
cannot be trimmed

11.8 Management of abruptio placentae
The specific management of abruptio placentae will depend on the general
condition of the client as well as on the status of the labour
Table 7. Management of abruptio placentae
Maternal shock OR massive Emergency C-S

bleeding OR early labour OR
no labour
Advance dilatation in multipara in Prompt vaginal delivery
stable patient
• Amniotomy
• Augmentation with oxytocin if
necessary
• Vacuum delivery
• Manual removal of placenta
• Uterine exploration and uterotonics
after placenta removal.
Strict haemodynamic monitoring after any of the above options. If bleeding

persists the client may require a conservative surgical treatment or a
hysterectomy to stop the bleeding

12.0 Postpartum Haemorrhage
12.1. Definition
• Early/primary postpartum haemorrhage: increased vaginal bleeding in the
first 24 hours after birth
• Delayed/secondary postpartum haemorrhage: increased vaginal bleeding
after the first 24 hours after birth and until the 6 weeks postpartum
Notes:
• The amount of blood is difficult to measure and usually underestimated.
Therefore, the classic definition of > 500 ml has been changed to “increased
vaginal bleeding”. This definition does also include vaginal bleeding that occurs
at a slow rate over several hours of time
• The client’s Hb level prior to delivery determines the effect of the blood loss as
well; the impact of a moderate bleeding in a severely anaemic client can easily
cause a shock as compared to a non-anaemic client

The main causes for a PPH can be summarised with the “four Ts”:
• Tone: uterine atony or hypotony is responsible for 70% of all PPHs
• Trauma: 20% of all PPHs are due to tears (vaginal, cervical, uterine)
• Tissue: 10% of all PPHs are due to retained placenta and/or membranes
• Thrombin: coagulopathies are responsible for <1% of PPHs
Some of them can overlap, e.g. a retained placenta can be followed by a uterine
atony and a continuous bleeding can set off a DIC

Table 7. Differential diagnosis of antepartum haemorrhage
Signs and symptoms
Uterine atony - Primary PPH

- Uterus soft and not contracted
- Placenta delivered complete
Trauma - Primary PPH

- Uterus contracted, placenta complete
- On examination (speculum required): cervical or vaginal tear
- On manual exploration of uterine cavity: hole or tear
Retained placenta - Primary PPH

- Uterus +/- contracted
- Placenta either not delivered after 30 minutes or incomplete on inspection
Primary coagulopathy - Primary PPH, maternal history of previous episodes of unexplained bleeding (e.g. bleeding during
teeth extraction)
- Uterus contracted
- No tears, neither retained tissue in uterine cavity
- Blood is not clotting
Secondary PPH - PPH after 24 hours of birth up to 6 weeks postpartum (amount of blood can be variable)
- Uterus softer and larger than expected for the corresponding postpartum time
- Sometimes foul-smelling discharge, signs of uterine infection-endometritis (tender, painful abdomen)
- Anaemia and poor general condition
- US: uterine with hyperechogenic irregular cavity, sometimes membranes or blood clots visible

12.3. Risk factors
• Uterine atony:
– Polyhydramnios
– Multiple pregnancy
– Foetal macrosomia
– Prolonged and obstructed labour
– Chorioamnionitis
– Previous PPH
– Labour induction and augmentation
– APH
• Trauma:
– Previous C-S or traumatic deliveries
– Instrumental delivery
– Macrosomia
• Retained placenta:
– Placental accretism and previous C-S
– Previous pregnancy with PPH due to retained placenta
• Coagulation disorders:
– Maternal blood disorders
– Pregnancy-induced hypertension (PIH)
– IUFD
– Abruptio placenta
– Any PPH can additionally complicate with a DIC

• Maternal anaemia
• Maternal death and disability
12.5. Prevention
(See Module 3 and Module 6)
• AMTSL in all pregnancies
• Close monitoring of immediate postpartum period
• Avoidance of routine episiotomy to avoid unnecessary bleeding
• Awareness and early recognition of abnormal blood loss
• Preventive treatment of anaemia during pregnancy
12.6. Management
• The patient should be in a CEmONC or stabilised and transferred as soon as
possible
• In case of transfer make sure that the bleeding is somehow controlled (uterine
tamponade, aortic compression in extreme cases) and the patient is under
constant fluid replacement and/or blood transfusion

Figure 9. Management of the first 30 minutes of a PPH
IMMEDIATE MANAGEMENT
• SHOUT FOR HELP. Mobilise all available personnel, including Gyn-Obs, anaesthetist, OT nursing team and
blood bank
• Organise the team: one at each arm, leading person between the legs, somebody to come and go for
medication/fluids/blood
• Document the time of start of management
• Rapid evaluation of general condition and vital signs
• ABC: open airway, oxygen 15 L/min, lie client flat, place 2 IV 16-18 G
• Crystalloid bolus (RL or NS): 1000 ml over 15 minutes
During the first 30 minutes
RESUSCITATION Specific management

• Reassess ABCD: start diagnosis and
(control of bleeding)
management of specific cause of PPH (assess • Uterine massage and manual removal of
for uterine tonus, tears, or retained placenta) placenta if not yet delivered (see Module 5)
• Send blood for Hb and crossmatching • Manual uterine exploration with sterile gloves,
analgesia and cefazoline 2 g IV
• Insert a Foley catheter
• Explore genital tract and repair any lacerations
• Target of resuscitation: SBP≥100mmHg,
SpO2≥95%, urine output ≥ 30ml/hour, patient • See for any signs of clotting disorders (oozing
conscious from IV sides, bloody urine, watery blood)
• Fluid replacement: continue with fluid boluses • In case of uterine atony:
(1 L in 15-20 minutes) as needed, but start blood
transfusion asap to avoid dilution coagulopathy. – Oxytocin: 5 IU slow IV push, then oxytocin
Aim to replace 2-3 times in crystalloids what you 20 IU (range 10 to 40) in 1L NS infuse 500 ml
calculated as loss over 10 minutes then 250 ml/hour
• Start tranexamic acid 1 g/10 ml administered 1. Misoprostol 800 mcg sublingually or rectally
slowly over 10 minutes OR in one of the 1L fluid (if sublingual not possible)
bags that are passing in 15 minutes 2. Methylergometrine 0.2 mg IM
• Warm the patient (cover with blanket, stop AC, 3. Intrauterine balloon (see obs procedures)
warm IV fluids)
• In case of massive PPH (>1500 ml):
• If bleeding persists after 30 minutes: repeat
tranexamic acid 1 g/10 ml slow IV infusion during 1. Bimanual uterine compression AND/OR
10 minutes (1 ml/min)
2. Aortal compression
3. Transfuse fresh whole blood (to manage
potential DIC)

Figure 10. Management after the first 30 minutes of PPH
After the first 30 minutes
If PPH subsided and patient is If PPH continues or is massive (OT):

stabilising: • Advanced resuscitation:
• Close monitoring:
– Continue fluid resus with RL/NS and blood
– Vital signs: every 10 minutes for the first
– Recheck Hb with hemocue
30 minutes, every 15 minutes for the next
30 minutes, every 30 minutes for the next – If required give vasopressors
6 hours
– Uterine tone and vaginal bleeding: every 30 • Surgical treatment
minutes – Conservative (experienced surgeon): B-lynch
– Continue maintenance IV fluid: 1L in 6 hours sutures or selective ligation of uterine artery/
internal iliac artery
– If uterine atony: keep maintenance of 20
IU oxytocin to pass in 12 hours (40 drops/ – Hysterectomy
min) or administer additional 200-800 mcg of
misoprostol rectally
– Oxygen: 6-8L/min
– Repeat Hb
• Assess the need of
Notes:
• Maximum total dose of oxytocin is 60 IU
• The IV push of oxytocin can make the client’s BP drop. Ensure a SLOW IV push and NOT a bolus
• Methylergometrine is contraindicated in hypertensive patients or heart disease. Keep as third line option and in case of
contraindication pass to step 4 with intrauterine balloon
• Maximum dose of misoprostol is 1600 mcg
• Tranexamic acid is recommended in ALL clients with PPH as soon as possible and within the first 3 hours. The only
exception in which tranexamic acid should be avoided is in clients with a clear contraindication to antifibrinolytic agents
such as a known thromboembolic event during pregnancy

Management of secondary postpartum haemorrhage
• Admission/referral to CEmONC
• Start IV antibiotics:
– Amoxicillin-clavulanic acid IV 875/125 mg every 8 hours PLUS gentamicin
IM/IV 5 mg/ kg once daily
OR
– Ampicillin IV 2 g every 8 hours PLUS metronidazole IV 500 mg every
8 hours PLUS gentamicin IV/IM 5 mg/kg once daily
Continue until the fever disappears or at least for 48 hours and continue with oral
antibiotics:
– Amoxicillin-clavulanic acid PO 1g/250 mg every 8 hours for 5 days OR
– Amoxicillin PO 1 g 3 times daily PLUS metronidazole PO 500 mg 3 times
daily for 5 days
• Perform US and confirm diagnosis of endometritis/retained products
• Evacuation of retained membranes:
– If cervical os open: try a digital curettage
– If cervical os closed: D&C or MVA (carefully, as risk of perforation)
Administer during or just after procedure: oxytocin 10 IU IM or misoprostol
800 mcg sublingually/rectally

13.0 References

CC BY-NC-SA 3.0 IGO
2019.
• Pregnancy, Childbirth, Postpartum and Newborn Care A Guide for
Essential Practice - 3rd ed. World Health Organization; 2016
NC-SA 3.0 IGO
• WHO recommendations on interventions to improve preterm birth
outcomes. Geneva: World Health Organization; 2015.
• Morris JM, Roberts CL, Bowen JR, Patterson JA, Bond DM, Algert CS,
Thornton JG, Crowther CA; PPROMT Collaboration. Immediate delivery
compared with expectant management after preterm pre-labour rupture of
the membranes close to term (PPROMT trial): a randomised controlled trial.
Lancet. 2016 Jan 30;387(10017):444-52.
• Middleton P, Shepherd E, Morris J, Crowther CA, Gomersall JC.
Induction of labour at or beyond 37 weeks’ gestation. Cochrane Database
of Systematic Reviews 2020, Issue 7. Art. No.: CD004945. DOI:
10.1002/14651858.CD004945.pub5.
• Delaney M, Roggensack A, Leduc DC, Ballermann C, Biringer A, Delaney
M, et al. Guidelines for the Management of Pregnancy at 41+0 to 42+0
Weeks. Journal of Obstetrics and Gynaecology Canada [Internet]. 2008
Sep [cited 2020 Oct 1];30(9):800–10. Available from: https://linkinghub.
elsevier.com/retrieve/pii/S1701216316329450
• Late intrauterine fetal death and stillbirth [Internet]. Green-top Guideline.
Vol. No. 55. RCOG; 2010. Available from: https://www.rcog.org.uk/
globalassets/documents/guidelines/gtg_55.pdf
• World Health Organization. Stillbirths [Internet]. [cited 2020 Oct 1]. Available
from: https://www.who.int/maternal_child_adolescent/epidemiology/
stillbirth/en/
• Misoprostol.org. How to dilute 200mcg of misoprostol in 200 ml water
[Internet]. [cited 2020 Oct 1]. Available from: http://www.misoprostol.org/
dilute-200-mcg-misoprostol-200ml-water/

• Morris JL, Winikoff B, Dabash R, Weeks A, Faundes A, Gemzell-
Danielsson K, et al. FIGO’s updated recommendations for misoprostol
used alone in gynecology and obstetrics. Int J Gynecol Obstet [Internet].
2017 Sep [cited 2020 Oct 2];138(3):363–6. Available from: http://doi.wiley.
com/10.1002/ijgo.12181
• Vogel JP, Oladapo OT, Dowswell T, Gülmezoglu AM. Updated WHO
recommendation on intravenous tranexamic acid for the treatment of post-
partum haemorrhage. The Lancet Global Health [Internet]. 2018 Jan [cited
2020 Oct 7];6(1):e18–9. Available from: https://linkinghub.elsevier.com/
retrieve/pii/S2214109X1730428X
• The Lancet. WOMAN: reducing maternal deaths with tranexamic acid. The
Lancet [Internet]. 2017 May [cited 2020 Oct 7];389(10084):2081. Available
from: https://linkinghub.elsevier.com/retrieve/pii/S014067361731111X
• World Health Organization. WHO recommendation on tranexamic acid for
the treatment of postpartum haemorrhage. [Internet]. 2017 [cited 2020 Oct
7]. Available from: http://www.ncbi.nlm.nih.gov/books/NBK493081/
• RCOG. Ectopic pregnancy. Clinical guidelines. 2017 Jun. (Intrapartum
NICE guidelines. RCOG guideline). Report No.: No: 10121.
• RCOG (2016) Prevention and Management of Post Partum Haemorrhage,
Green Top Guideline No. 52. RCOG. International Journal of
Obstetricians and Gynaecology. Accessed at: https://www.rcog.org.uk/en/
guidelinesresearch-services/guidelines/gtg52/

Module 5
1
Antenatal Procedures
Obstetric Care
Module 5: Obstetric Procedures
Contents 7.0 Repair of Perineal Tears 5.17

7.1. Definition and degrees 5.17
1.0 Manual Removal of Placenta 5.3
7.2. Indication for repair 5.17
1.1. Definition 5.3
1.2. Indication 5.3
7.4. Technique 5.18
1.3. Contraindications 5.3
1.4. Risks/complications 5.3 8.0 Repair of Cervical Tears 5.22
1.5. Technique 5.4 8.1. Definition 5.22
8.2. Indication for repair 5.22
2.0 Manual Uterine Exploration 5.6
2.1. Definition 5.6
8.4. Technique 5.23
2.2. Indication 5.6
2.3. Contraindication 5.6 9.0 Deinfibulation 5.24
2.4. Risks/complications 5.6 9.1. Definition 5.24
2.5. Technique 5.7 9.2. Indication 5.24
9.3. Complications 5.24
3.0 Bimanual Uterine Compression 5.8
9.4. Technique 5.25
3.1. Definition 5.8
3.2. Indication 5.8 10.0 Breech Delivery 5.26
3.3. Technique 5.8 10.1. Definition 5.26
10.2. Indication 5.26
4.0 Aorta Compression 5.10
10.3. Contraindication 5.27
10.4. Complications 5.27
10.5. Technique 5.28
4.4. Technique 5.10 11.0 External Cephalic Version 5.33
5.0 Intrauterine Balloon Tamponade 5.12
5.5. Technique 5.13 12.0 Internal Version and Breech Extraction 5.36
6.0 Episiotomy 5.14
6.5. Technique 5.15
13.0 Twin Delivery 5.38 17.0 Caesarean Section 5.51
13.1. Definition 5.38 17.1. Definition 5.51
13.2. Indications for each type of delivery 5.38 17.2. Indication 5.52
13.3. Risks/complications 5.38 17.3. Contraindication 5.52
13.4. Technique: vaginal delivery of twins 5.39 17.4. Risks/complications 5.52
17.5. Care for uncomplicated C-S 5.53
14.0 Vacuum Delivery 5.40
17.6. Humanised C-S practice 5.56
12.2. Indication 5.40 18.0 Induction of Labour 5.58
12.3. Contraindication 5.40 18.1. Definition 5.58
12.4. Risks/complications 5.40 18.2. Indication for induction of labour 5.58
12.5. Technique 5.41 18.3. Indication for augmentation of labour 5.59
15.0 Manoeuvre for Shoulder Dystocia 5.43
18.5. Methods 5.60
18.6. Contraindications 5.62
15.2. Indication of the manoeuvre 5.43
18.7. Management of complications 5.63
15.3. Risks/complications of shoulder 5.43
dystocia and its manoeuvre 19.0 References 5.64
16.0 Vaginal Birth After Caesarean Section 5.49


1.0 Manual Removal of Placenta
Reminder: consent is mentioned frequently in the following

sections. Informed consent can be written or verbal. Written
consent is not simply a signature on a piece of paper; it is a
process in which the clinician explains an intervention to a client
and responds to their questions and doubts, allowing them to
make an informed decision about their care
1.1. Definition
Evacuation of the placenta from the uterus with the hand
1.2. Indication
• Retained placenta (no expulsion of placenta after 30-45 minutes after
delivery)
• PPH before expulsion of placenta
1.3. Contraindications
Placenta accreta
• Vasovagal reaction due to pain and discomfort during the procedure that
can lead to a loss of consciousness of the client
• PPH
• Endometritis/infection if procedure does not follow aseptic technique and
client does not receive antibiotic prophylaxis

1.5. Technique
• Explain the procedure to the client and birth partner
• Insert an IV line 16-18 G with maintenance fluid and make sure the client
has an empty bladder
• Analgesia and/or sedation (see pain management)
• Before procedure: cefazoline 2 g IV stat dose OR ampicillin 2 g IV stat dose
• Clean vulva and perineum with clean water or povidone, place
sterile drapes on abdomen, on legs and under buttocks. Use sterile
gynaecological gloves
• Hold down the uterine fundus with the non-dominant hand through the
abdominal wall
• Insert the dominant hand in the vagina and uterine cavity following the
umbilical cord until reaching the placenta
• Move the hand until locating the edge of the placenta
• Keep the fingers together and the palm facing towards the placenta.
Move hand laterally along the cleavage plane until the whole placenta is
separated
• Extract the placenta and immediately perform a uterine exploration to
make sure no membranes have been left behind
• Administer oxytocin 10 IU IM. If bleeding occurs, follow PPH management

(see Module 4)
• Monitor vital signs, uterine tone, and vaginal bleeding every 15-30 min
during the next 2 hours
• Document the procedure, including its indication and antibiotic
prophylaxis
• In rare occasions, the placenta will not separate from the uterine wall
due to a placenta accreta: refer immediately for further management
(a hysterectomy will be required)

Figure 1. Manual removal Introducing one hand into the vagina along the cord
of placenta
Supporting the fundus while removing the placenta

2.0 Manual Uterine Exploration
2.1. Definition
Manual exploration of the uterine cavity to rule out retained membranes,
uterine tears, etc.
2.2. Indication
• Primary PPH to identify any retained tissue
• Routinely after performing a manual removal of placenta
• Suspected retained membranes and products after examination of placenta
• Suspected uterine rupture
2.3. Contraindication
Lack of appropriate infection prevention and analgesia measures
• Vasovagal reaction due to pain and discomfort during the procedure that
can lead to a loss of consciousness of the client
• PPH
• Endometritis/infection if procedure does not follow aseptic technique and
antibiotic prophylaxis is not provided

2.5. Technique
• Explain the intervention to the client and birth partner
• Insert IV line 16-18 G with maintenance fluid and make sure the client has
an empty bladder
• Provide appropriate analgesia (see pain management)
• Before procedure: cefazoline 2 g IV stat dose OR ampicillin 2 g IV stat dose
• Clean vulva and perineum with clean water or povidone, place
sterile drapes on abdomen, on legs and under buttocks. Use sterile
gynaecological gloves
• Hold down the uterine fundus with the non-dominant hand through the
abdominal wall
• Insert the dominant hand in vagina and uterine cavity
• Examine all the uterine cavity following an order: anterior and posterior
face, fundus, horns and both sides
• Extract any placental tissues, membranes, or clots
• Monitor closely during the next 2 hours

3.0 B
imanual Uterine
Compression
3.1. Definition
Compression of the uterus with one hand in the vagina and one hand
on the abdomen
3.2. Indication
Uterine atony with acute/massive PPH
3.3. Technique
• Explain the procedure to the client and birth partner in the context of an
acute PPH
• If there is time: analgesia or sedation and cefazoline 2 g IV stat dose
• Wear sterile gynaecological gloves
• Insert the dominant hand into the vagina and form a fist or leave fingers
extended placed in the anterior fornix
• The non-dominant hand will be located at the uterine fundus and posterior
uterine wall through the abdomen
• Apply intense pressure through the anterior fornix to the anterior uterine
wall, meanwhile the non-dominant hand presses deeply into the abdomen
and behind the uterus, applying pressure to the posterior uterine wall
• Maintain pressure until bleeding is controlled and uterus starts contracting
• Apply PPH protocol at the same time (general management PLUS uterotonics)
• After the patient is stabilised start broad spectrum antibiotics for 7 days:
ampicillin 1g every 8 hours IV PLUS metronidazole 500 mg every 8 hours
IV OR amoxicillin-clavulanic acid 875/125 mg every 8h IV for 48 hours and
then continue with oral until 5 additional days have been completed

Figure 2. Bimanual uterine
compression

4.0 Aorta Compression
4.1. Definition
Compression of the aorta through the abdominal wall as a last resource
measure in cases of massive PPH
4.2. Indication
Control of bleeding in a massive PPH to gain time meanwhile other measures
are applied (e.g. starting laparotomy or inserting an intrauterine balloon)
The aorta compression stops or limits drastically the blood flow to the lower half
of the body. It is therefore a temporary measure that cannot be maintained
further than few minutes
4.4. Technique
Apply downward pressure with a closed fist just above the umbilicus and
slightly to the left and feel the femoral pulse at the same time. If the pulse is not
detectable the pressure is adequate, if the pulse is yet detectable the pressure
needs to be increased or the fist relocated
The pressure needs to be maintained until the bleeding is controlled with further
measures

Figure 3. Aorta compression

5.0 I ntrauterine Balloon
Tamponade
5.1. Definition
Introduction inside the uterine cavity of a balloon that when inflated, will apply
pressure to the uterine walls and help stop bleeding
5.2. Indication
Control of PPH when uterotonic drugs and manoeuvres have failed. It may assist
in BEmONC settings to allow a safe referral to a CEmONC
• Uterine rupture
• Established purulent infection of uterus, cervix or vagina
• Postprocedural infection (endometritis)
• Failure of procedure

5.5. Technique
Depending on the manufacturer, slightly different techniques are described for
the insertion and inflation of the balloon. However, for all types of devices the
following points apply:
• A PPH protocol should be in place (blood transfusion, Foley catheter,
monitoring, O2, etc.)
• Pain management
• Sterile gloves and drapes, antiseptic technique, clean vulva and perineum with
clean water or povidone before starting the procedure
• Infusion of oxytocin (see PPH protocol)
• Ampicillin 1 g every 8 hours IV PLUS metronidazole 500 mg every 8 hours IV
until balloon is removed OR amoxi-clavulanic acid 875/125 mg every 8 hours
IV until balloon is removed
• Monitor uterine contraction, vaginal bleeding and vital signs every 15-30
minutes during the first 6 hours, and then every 4 hours for 24 hours
• After 24 hours attempt to deflate progressively the balloon and allow
progressive uterine contraction. Continue oxytocin infusion for another 12-24
hours or administer misoprostol 600-800 mcg rectally/sublingually
• If the tamponade fails to contain the bleeding (or bleeding reoccurs), immediate
surgical management is indicated

6.0 Episiotomy
6.1. Definition
Surgical cut made during childbirth to enlarge the soft tissue birth canal. The cut
usually involves perineal skin, vagina and perineal subcutaneous and muscle
layer
6.2. Indication
Episiotomy is not a routine procedure in vaginal deliveries. Episiotomies can be
considered in following situations:
• Shoulder dystocia
• Instrumental delivery
• Prolonged expulsive state when the perineum is obstructing the passage
of foetal head or when there is an indication to expedite delivery (e.g. foetal
distress)
• Previous history of third or fourth degree tears
• FGM type I and II: excision of clitoris and minor labia can cause a rigid
perineum (scar tissue) that can block delivery and easily tear
Any situation when episiotomy is not strictly needed
• PPH
• Postpartum infection
• Postpartum pain
• Dyspareunia
• Perineal scar and less distensibility for next delivery

6.5. Technique
• Clean perineum with clean water or povidone iodine 10%
• ALWAYS administer local anaesthesia (lidocaine 1% 10 ml)
• Perform mediolateral episiotomy during a push of the client (ideally when
perineum is distended and thin)
• The sterile scissors used for the episiotomy must not be used to cut the cord
• After delivery of the baby and placenta proceed to repair the episiotomy:
– Start the repair about 1 cm above the top of the episiotomy
– Apply a continuous suture from the top to the vaginal introitus with an
absorbable suture number 1-0 or 1
– At the introitus ensure anatomical alignment and finish the continuous suture
with a knot. Make sure you do not narrow the vaginal opening
– Apply interrupted sutures (number 1-0, absorbable sutures) to the
subcutaneous tissue to avoid a dead space. Make sure you do not
accidentally suture the rectum
– Close the perineal skin with interrupted absorbable 2-0 sutures. Make sure
the stiches are not too tight (avoid oedema and unnecessary discomfort)
– Perform a rectal exam to make sure there are no accidental stiches to the
rectum. The glove for the rectal exam needs to be discarded immediately
• Document the procedure including its indication
• Advise the client on postpartum care of the episiotomy: wash with water and
soap twice daily and maintain dry. Provide analgesia for postpartum period

Figure 4. Episiotomy and
episiotomy repair
Operating
scissors
Foetal head
bulging
Vaginal
Medio-Lateral opening
episiotomy
Midline
episiotomy
Anus
A. Vaginal mucosa B. Muscle layer C. Skin

7.0 Repair of Perineal Tears
7.1. Definition and degrees

Any tear involving the vulva, vagina, perineum, and adjacent structures (anus,
rectum, urethra)
• First degree tears: tears that involve only superficial skin of the vulva or
perineum
• Second degree tears: tears involving skin, vaginal mucosa, and subjacent
layer without involving the anal sphincter muscle
• Third degree tears: tears involving anal sphincter muscle
• Fourth degree tears: tears involving rectal mucosa
7.2. Indication for repair

• First degree tears may heal spontaneously
• Second, third and fourth degree tears require immediate suturing after delivery
of placenta
• Third and fourth degree tears need to be repaired in a CEmONC
• PPH
• Postpartum infection
• Postpartum pain
• Faecal incontinence in third and fourth degree tears
• Dyspareunia
• Perineal scar or less distensibility for next delivery

7.4. Technique
7.4.1. First degree tears
Most 1st degree tears heal spontaneously without any need for intervention
• If tear is bleeding: apply pressure for 1-2 minutes and reassess
• If bleeding after pressure continues, apply interrupted absorbable sutures
(2-0 or 3-0)
7.4.2. Second degree tears

• Apply antiseptic solution to the area around the tear (povidone iodine 10%),
check for any allergies to lidocaine/related drugs
• Lidocaine 1% 10 ml:
– Infiltrate beneath the vaginal mucosa, beneath the skin of the perineum and
deeply into the perineal muscle and tissue
– Every time the needle is introduced, check by aspiration if no blood vessel
has been penetrated
– Wait 2 minutes and check status of anaesthesia before starting to suture
• Suturing: same procedure as for episiotomies
• Document the procedure including a detailed description of the tear(s)
and its repair
• Advise the woman on the postpartum care of the sutured areas: wash
with water and soap twice daily and maintain dry. Provide analgesia for
postpartum period

7.4.3. Third degree tears
• Administer prophylactic antibiotic with cefazolin IV 2 g PLUS metronidazole
500 mg IV single dose
• Insert one finger in the rectum to locate the ends of the torn muscle by
elevating the finger slightly and exposing the edges (glove needs to be
changed if finger is taken out)
• Suture first the sphincter with absorbable 3-0 mattress sutures. Usually no
more than 2-3 sutures are needed
• Continue same sequence as for episiotomy
• Document the procedure including a detailed description of the tear(s)
and its repair
• Provide laxative during the first 7 days postpartum period to avoid hard stool
passage
• Provide adequate analgesia
• No routine antibiotics are needed besides the prophylactic stat doses. Only in
case of signs of infection start with amoxicillin-clavulanic acid 1 g every 8 hours
for 7 days

7.4.4. Fourth degree tears
• Administer prophylactic antibiotic with cefazolin IV 2 g PLUS metronidazole
500 mg IV single dose
• Place a compress in the rectum to avoid faecal material contaminating the field
• Start by suturing rectal mucosa with absorbable interrupted suture (3-0 or 4-0)
starting at 0.5 cm above the highest edge of the tear
• Follow with the same sequence as in third degree tear
• Provide laxative during the first 7 days postpartum period to avoid hard stool
passage
• Provide adequate analgesia
• No routine antibiotics are needed besides the prophylactic stat doses. Only in
case of signs of infection start with amoxicillin-clavulanic acid 1 g every 8 hours
for 7 days

Figure 5. Fourth degree perineal
tear and its repair
Anal sphincter Perineal muscles

(torn) (torn)
Orientation
to surgical
illustrations
1. Lacerated 2. Closure of rectal 3. Closure of endo-
perineum mucosa with pelvic fascia with
before repair running suture interrupted suture
4. Closure of anal 5. Closure of 6. Subcutaneous 7. Subcuticular

sphincter with perineal muscles tissue of closure of
interrupted suture with interrupted perineum re- the skin
suture approximated

8.0 Repair of Cervical Tears
8.1. Definition
Laceration of the cervix during vaginal deliveries
8.2. Indication for repair

Deep cervical tears or cervical tears that are bleeding
• PPH
• Cervical scars that compromise cervical dilatation in subsequent
pregnancies
• Vesicovaginal or rectovaginal fistula when the tears extend deeply

8.4. Technique
• Inform the client and birth partner
• In deep cervical tears or the ones that may take a longer time to repair
appropriate sedation and analgesia needs to be provided to the client
• Aseptic technique: sterile gloves, clean perineum and vulva with povidone
iodine 10%. Use new sterile drapes
• Ask an assistant to massage the uterus and provide fundal pressure, so that
the cervix is more easily visible
• Gently grasp the cervix with ring or sponge forceps at the 12 o’clock position.
Apply the second ring forceps away from the first. With the help of the third ring
forceps, if available, gently move on in a clockwise direction to see the entire
cervix as there may be several tears
• Apply two ring forceps on either side of a detected cervical tear
• Close the cervical tear with continuous 1-0 absorbable suture starting 0.5 cm
above the upper edge of tear
• A laparotomy may be required to repair a cervical tear that has extended deep
beyond the vaginal vault: be aware that suturing wide cervical tears that extend
high may accidentally ligate the ureter
• If aseptic technique has been used there is no need for prophylactic antibiotics
Figure 7. Repair of cervical tear

9.0 Deinfibulation
9.1. Definition
Minor surgical procedure to open the vagina in a client with FGM type III
9.2. Indication
• FGM type III (removal of clitoris, minor and major labia and sealing of the
edges of major labia to occlude the vulva and vaginal introitus)
• The deinfibulation is ideally offered during ANC and performed at around
20 weeks. Alternatively, it can be done at delivery
Double episiotomy is NOT an acceptable option for clients with type III FGM.
Re-infibulation is NOT an acceptable option after delivery
9.3. Complications
Very low risk as it is a minor intervention: infection, minor haemorrhage,
minor discomfort and pain

9.4. Technique
• Counsel the client and obtain written informed consent
• Apply antiseptic solution to the area around the tear, check for any allergies
to lidocaine/related drugs
• Infiltrate 10 ml of lidocaine 1% solution in the midline tissue (check by
aspiration that no blood vessel has been penetrated). Wait 2 minutes and
check status of anaesthesia before starting
• Insert one finger in the opening of the vulva and place it posterior of the
scar tissue to protect the urethra
• With the other hand use scissors to cut open the scar tissue
• If edges are bleeding after the cut: suture along each side-edge with
interrupted stiches of absorbable suture 2-0 or 3-0
• Same postoperative care as for perineal tears/episiotomy
Figure 8. Deinfibulation

10.0 Breech Delivery
See also breech presentation in complications of labour
10.1. Definition
Vaginal delivery of a baby with breech presentation
10.2. Indication
A breech presentation alone is not an indication for C-S. A vaginal delivery
can be attempted even in primiparous clients
All breech deliveries should take place in a CEmONC and with the presence
of an experienced provider
Favourable factors for vaginal delivery are:

• Frank breech presentation
• A history of vaginal delivery (whatever the presentation)
• Normally progressing dilation during labour

• Non-experienced provider
• BEmONC setting
• Any contraindications for vaginal birth such as cord presentation, placenta
previa, compromised foetal condition, etc.
• Previous C-S or any other uterine scar
• Hyperextended foetal neck in labour (diagnosis with US at the start of labour)
• Twin pregnancy in which the first twin is breech
• Any other presentation other than frank or complete breech
• Clinically inadequate maternal pelvis
• Large baby (estimated >3800 g)
• Foetal growth restriction or prematurity (<2000 g, <36 weeks)
10.4. Complications
• Perineal tears in the mother
• Newborn birth injury such as femur fractures
• Cord prolapse

Figure 9. Breech delivery,
holding baby by hips
10.5. Technique
without pulling • Counsel the client and obtain written informed consent
• Insert an IV line and provide appropriate pain management for labour
• Do not allow the client to push until cervix is fully dilated and foetal buttocks
have entered pelvis
• The breech delivery should go mostly unaided and guided by the pushes
of the mother
10.5.1. Delivery of buttocks and legs

• Hands off: do not attempt any manoeuvre touching the baby until buttocks
and legs are delivered and shoulder blades are visible. Touching the baby
before will trigger a respiratory reflex in the baby. Pulling the baby before
the complete delivery of legs and buttocks increases greatly the risk of an
entrapped after-coming head
• When buttocks are crowning, evaluate the need for an episiotomy
• Once the umbilicus is visible the rest of the delivery needs to be finalised
within 3 minutes to avoid foetal hypoxia due to cord compression
• Hold the baby by the hips and keep back of baby always anterior.
Never pull the legs or hold the baby by the abdomen
10.5.2. Delivery of the arms (arms on chest)

After spontaneous delivery of the first arm, lift the buttocks towards the
mother’s abdomen to enable the second arm to deliver spontaneously
10.5.3. Delivery of the head

The delivery of the head can happen unaided. When the delivery of the
head does not happen immediately, apply below manoeuvres to support
its delivery

10.5.4. Management of obstructed shoulders
Shoulder can get stuck and obstruct the delivery when the foetal arms are
stretched above the head
• Lovset’s manoeuvre:
– Hold the baby by the hips (thumbs on sacrum)
– Turn the baby 90º (back is facing right or left, whichever side turns
more easily) so that one shoulder is anterior underneath the pubis
– Gently apply downward traction to expose the shoulder and place 2
fingers on the upper part of the arm
– With the 2 fingers in the foetal upper arm, help to flex foetal elbow and
deliver the anterior arm
Figure 10. Lovset’s – Turn the baby 180º to place the posterior shoulder underneath the pubis
manoeuvre and repeat the same (traction down, deliver arm)

• Suzor’s manoeuvre (apply when Lovset fails)
– Turn infant 90º (back to the right or left, whichever side turns more easily)
– Pull the infant downward and insert one hand along foetal back until you
find the anterior arm. Place your thumb in the foetal armpit and middle
finger on the upper arm and flex and bring down the arm
Figure 11. Suzor´s – Lift the infant upward by the feet (or help of an assistant) and do the
manouevre same with the posterior arm (without turning the baby 180º)

10.5.5. Management of entrapped head
A head that does not delivery immediately after the shoulders may be
entrapped and needs immediate management
The aim of the below manoeuvres is to support and achieve the flexion of the
foetal head allowing its delivery
Before starting:
• Ensure the client’s bladder is empty
• Have an assistant ready
• Prepare for foetal resuscitation
Figure 12. Mauriceau Smellie • Mauriceau Smellie Veit manoeuvre

Veit manoeuvre
– Lay the baby face down with the length of its body over your dominant
hand and arm
– Place the first and third finger of the dominant hand on the baby’s maxilla
(upper jaw cheekbones). NEVER put the fingers inside the baby’s mouth
– Use the other (non-dominant) hand to grasp the baby’s shoulders
– With the fingers on the baby’s upper jaw cheekbones, gently flex the
baby’s head towards the chest by applying downward pressure on the
jaw to bring the baby’s head down until the hairline is visible
– At the same time, an assistant can support by pushing above the
mother’s pubic bone as the head delivers. This helps to keep the baby’s
head flexed
– Raise the baby until the mouth and nose are free

Figure 13. Bracht’s • Bracht’s manoeuvre
manoeuvre
– After delivery of the arms grasp the baby by the hips and lift it towards
the mother’s stomach without pulling
– An assistant applies suprapubic pressure to facilitate the flexion and
delivery of the head
• In case none of these manoeuvres have released the head, forceps can be
applied (only by experienced obstetrician)
• If forceps fail, expectant management is the only remaining solution:
– Make sure there are contractions (augment with oxytocin if required). Closely
monitor the client’s pain and contractions; a uterine rupture is not uncommon
in these situations
– Wait for spontaneous delivery of head
– Foetal demise is almost sure. Inform and support the client and birth
partner
– Counsel client and birth partner. Provide analgesia
– DO NOT ATTEMPT C-S
– In rare cases (e.g. entrapped head due to hydrocephalus) a destructive
delivery with craniotomy can be indicated

11.0 External Cephalic Version
11.1. Definition
Procedure in which the foetal presentation is converted from a breech to a
cephalic presentation or from a transverse lie to a longitudinal cephalic or
breech presentation
11.2. Indication
Pre-labour breech or transverse lie
Pre-Conditions:
• Experienced provider in a CEmONC
• 37 weeks confirmed GA
• Prior to the start of labour
• Relaxed uterus
• No contraindication for vaginal delivery
• Membranes intact
• Placenta previa or any other APH
• Twin pregnancy
• Previous C-S or uterine scar
• Oligohydramnios
• Ruptured membranes
• Intrauterine growth restriction (<2000 g estimated birth weight)
• Prematurity (<37 weeks)
• Foetal distress
• Any contraindication for vaginal birth
• Preeclampsia (due to increased risk of abruptio)

• Foetal distress
• Foeto-maternal haemorrhage
• Rh sensitisation of Rh negative client if no anti-D provided with the
procedure
• Abruptio placentae
• Uterine rupture
• PROM or start of labour
11.5. Technique
• Insert an IV line and advise the client to empty their bladder
• Client must lie on their back with legs slightly elevated and bent
• Check foetal heart rate to make sure there no abnormalities before starting
the procedure
• To mobilise the breech, gently lift the lowest part of the foetus from the
pelvic inlet by grasping above the pubic bone
• Bring the head and buttocks of the foetus closer to each other to achieve
forward rotation (in the direction of the flexion of the heard)
• Rotate the foetus slowly by guiding the head in a forward roll as the
buttocks are lifted
• Listen to the foetal heartrate. If an abnormality is detected:
– Have the client turn onto the left side
– Give oxygen at 15 L per minute by mask or nasal cannula
– Reassess every 5 minutes. If the foetal heartrate does not stabilise within
the next 15 – 30 minutes, deliver by C-S

• If the procedure is successful, have the client remain lying down for 15
minutes. Counsel the client to return if bleeding or pain occurs or if they
believe the baby has returned to the previous presentation
• If the procedure is unsuccessful try to rotate backwards. If still unsuccessful
counsel on planned C-S or allow breech vaginal delivery
• Administer anti-D prophylaxis if client is Rh negative
Figure 13. External cephalic

version
A. Mobilisation of the breech B. Manual forward roll using both

hands, one to push the breech
and the other to guide the vertex
C. Completion of the forward roll D. Alternative to forward roll is a

backward roll

12.0 I nternal Version and Breech
Extraction
12.1. Definition
Intrauterine manoeuvre in which a transverse lie is converted into a breech
presentation
12.2. Indications
Transverse lie or unstable presentation in a second twin
Pre-Conditions:
• Complete dilatation
• Normal pelvis
• Presenting part not engaged
• Emptied bladder
Intact membranes facilitate the manoeuvre but are not a pre-condition for
performing the procedure
• Any contraindication for vaginal delivery
• Engaged or impacted presenting part
• Uterine rupture
• Foetal distress
• Birth injuries
• Perineal tears

Figure 14. Internal version and
breech extraction
12.5. Technique
• Insert an IV line and advise the client to empty their bladder
• Use sterile gynaecological gloves, drapes and clean the perineum and
vulva with povidone iodine 10%
• Administer antibiotics as for all intrauterine procedures:
– Ampicillin 2 g IV PLUS metronidazole 500 mg IV (single dose)
OR
– Cefazolin 1 g IV PLUS metronidazole 500 mg IV (single dose)
• Hold fundus with the non-dominant hand
• Introduce dominant hand in vagina and determine foetal presentation
• Gently introduce the hand in the uterus and locate and grasp the foetal feet.
Ideally, grasp both feet
• Pull both feet gently out and through the vagina
• Continue traction until buttocks are seen and proceed with breech delivery
manoeuvres
• After delivery of the placenta do a quick manual exploration to exclude any
uterine rupture

13.0 Twin Delivery
13.1. Definition
Birth of a multiple pregnancy
13.2. Indications for each type of delivery

Vaginal delivery:
Twin pregnancy that is diamniotic (each twin in one amniotic sac) and:
• Both twins cephalic
• First twin cephalic and second twin breech or transverse
C-S will be planned (week 38-39) when:

• First twin lies in breech or transverse presentation
• Any other contraindication for vaginal birth (e.g. placenta praevia)
• Twin pregnancy that is monoamniotic
• Multiple pregnancy with >2 babies
• Any condition requiring ending of pregnancy (e.g. pre-eclampsia
with severe features) but Bishop score <6
Cervical ripening and induction with misoprostol are contraindicated
• Birth injuries
• Perineal tears
• Uterine rupture
• Uterine atony

13.4. Technique: vaginal delivery of twins
• Insert IV line and ensure the client’s bladder is empty
• Deliver first twin as it would be a single cephalic normal delivery
• Cut cord without delay and leave a clamp. There might be a single placenta
for both twins or communicating vessels between both placentas and
therefore a delayed cord-clamping of the first twin could lead to its anaemia
• Immediately after delivery of the first twin, an assistant should hold the
position of the second twin into a vertical presentation by applying both
hands on the sides of the uterus
• Continue FHR monitoring of the second twin every 5 minutes and explore
its presentation
• Rest period between twins (period without contractions) should not take
longer than 15-30 minutes. If there are no contractions within 30 minutes of
the delivery of the first twin, start oxytocin drip (5 IU in 500 ml or 10 IU in 1 L,
starting with 5 drops/minute and increase by 5 drops/minute every 5 min until
contractions begin)
• Delivery of second twin:
– Cephalic or breech: follow usual manoeuvres
– Transverse: internal version and breech extraction or external rotation
during rest period
• Third stage: routine AMTSL and monitor for PPH. PPH is more frequent in
twin deliveries due to the hyperextended uterus

14.0 Vacuum Delivery
14.1. Definition
Assisted vaginal delivery that uses a ventouse (vacuum cup) and negative
applied pressure
14.2. Indication
• Prolonged second stage of labour with foetal head engaged
• Any reason to shorten expulsive stage e.g. foetal distress, maternal
exhaustion, etc.
Pre- Conditions:
• Full dilatation
• Cephalic presentation
• Membranes ruptured
• Foetal head engaged (0 station or at least 2/5 above symphysis)
• ≥ 34 weeks confirmed GA
• Any contraindication for vaginal delivery
• Any presentation other than cephalic
• < 34 weeks
14.4. Risks
• Cephalohematoma
• Scalp abrasions and lacerations
• Intracranial bleeding
• Perineal tear

Figure 15. Vacuum delivery 14.5. Technique
• Inform the patient and birth partner
• Check the equipment (test vacuum with gloved hand)
• Insert IV line and ensure client’s bladder is empty
• Sterile gloves and drapes, clean vulva and perineum with clean water or
povidone iodine 10%
• Provide analgesia and anaesthesia: ideally a pudendal block and if not
possible at least administer a perineal infiltration of lidocaine as for an
episiotomy
• Assess the position of the foetal head and identify the posterior fontanelle
(which is the smaller fontanelle along the sagittal suture). The so called
“flexion point” is 1 cm anterior to the posterior fontanelle
• Apply the vacuum cup (the largest one that fits) over the flexion point
• Check that there is no cervical or vaginal tissue between cap and foetal
scalp
• Start with 0.2 kg/cm2 of pressure and check again the correct position of
the cup as well as no tissue trapped
• Increase vacuum to 0.8 kg/cm2 and recheck
• Increase until maximum vacuum (usually 1-1.2 kg/cm2)
• Position the thumb of the non-dominant hand on the cup and the index
finger (of the same hand) on the foetal head to control potential slippage
whilst pulling
• Wait for a contraction to start, ask the client to push and apply traction
perpendicular to the cup and approximately 45º downwards (follow the line
of the pelvic axis). Sometimes the traction needs to be directed towards
the line that will correct an asynclitism (to the sides or more markedly
downwards to correct flexion)
• Ask an assistant to check FHR after each contraction/pull
• Continue pulling with each contraction and client’s push. If the foetal
head is descending with each pull and there is no foetal distress, you can
continue up to a maximum of 30 minutes

• When head is crowning assess for episiotomy
• When head is delivered: remove pressure and release the cup.
Complete the delivery
• Revise vagina and cervix to ensure there are no tears
• Revise baby to identify any birth trauma
Do not:
• Rotate the baby’s head (this will happen naturally with the traction)
• Pull between contractions
• Give antibiotics if there is no other indication
Give up (failed vacuum extraction) if:

• More than 30 minutes have passed with active pulls (even if descending)
• More than 3 pulls have been performed without descent
• The cup has slipped off more than twice
If vacuum fails, perform immediate C-S

15.0 Manoeuvre for Shoulder
Dystocia
15.1. Definition
Shoulder dystocia happens when the shoulders are impacted in the pelvis
and do not allow the delivery of the rest of the body
Shoulder dystocia CANNOT be predicted neither prevented. It is a life-
threatening emergency for the foetus
15.2. Indication of the manoeuvre

Signs of shoulder dystocia are:
• Turtle sign: retraction of the baby´s head once it attempts to exit
• No external rotation of the head
• Red puffy, flushed face of baby
• Failure to proceed with delivery despite routine manoeuvres
Risk factors for shoulder dystocia:

• Suspected foetal macrosomia
• Maternal diabetes
• Post-term pregnancy
• Multiparity
• Obesity
15.3. Risks/complications of shoulder

dystocia and its manoeuvre
• Foetal asphyxia and distress
• Birth injuries: brachial plexus palsy, clavicle fracture humerus fracture
• Perinatal death
• PPH
• Perineal tears
• Uterine rupture

Figure 16. McRoberts
manoeuvre
15.4. Technique
Use the HELPERR mnemonic
H Call for Help

E Evaluate Episiotomy
L Legs hyperflexed (McRoberts Maneouvre)
P Suprapubic Pressure
E Enter pelvis for internal rotation of shoulders
R Remove the posterior arm
R Roll the patient to “all fours”
• Call for help without delay. You will need 2 or 3 assistants (birth partner
can help in case of need)
• Ask the client to stop pushing to avoid further impaction of the shoulder in
the pelvic brim
• Record the time of delivery of the head and briefly inform the client and
birth partner of the emergency
• Prepare for neonatal resuscitation
• Evaluate the need of an episiotomy: the shoulder dystocia is not a
problem of soft tissues, but the episiotomy may allow for additional space to
perform the manoeuvres needed
• The time for attempting each of the following manoeuvres should be
between 30-60 seconds, passing to the next one if it was not successful.
Assistant needs to keep track of time and inform the provider every
30‑60 seconds
• McRoberts manoeuvre: hyperflexion of pelvis and legs. Two assistants
will help to push the knees of the client towards the chest while the
provider gently but firmly pulls the foetal head downwards. 70% of shoulder
dystocias are resolved with this manoeuvre

• Suprapubic pressure: can be applied at the same time as the McRoberts
manoeuvre. A second assistant will apply pressure just above the
symphysis pubis. The aim is to reduce the diameter between the foetal
shoulders and help free the anterior shoulder
Figure 17. Suprapubic pressure
• Enter pelvis: start internal manoeuvres to rotate the baby. Keep legs
hyperflexed
– Rubin’s manoeuvre: insert fingers behind the anterior shoulder and
push firmly towards the foetal chest to slight rotate the baby and free
the anterior shoulder
Figure 18. Rubin’s manoeuvre

Figure 19. Wood’s corkscrew – Wood’s corkscrew manoeuvre: at
manoeuvre the same time that doing Rubin’s, place
fingers of the other hand against the
front of the posterior shoulder and push
firmly to help rotate the baby and free
shoulder
Figure 20. Reverse Wood’s – Reverse Wood’s corkscrew

corkscrew manoeuvre manoeuvre: if the internal rotation is
not successful try the same but in the
opposite direction

• Remove the posterior arm
– Aim to insert fingers to remove posterior arm, sweeping across front of
the foetal body
– The arm is usually flexed at the elbow. If it is not, pressure in the
antecubital fossa can assist with flexion
– The hand is grasped, swept across the chest and delivered, as shown
in Figure 21. This may lead to humeral fracture, which does not cause
permanent neurological damage
Figure 21. Removal

of posterior arm
• Roll the patient on “all fours”: This manoeuvre will increase the pelvic
diameters and allow an easier access to free the posterior shoulder
Figure 22. Patient on

“all fours” position

• If none of the manoeuvres has worked:
– Fracture the baby’s clavicle to shorten diameter between shoulders
Figure 23. Fracture of baby’s

clavicle
– Symphysiotomy can be performed as last resort. If it comes to this

stage, there is most probably already a foetal demise and a destructive
delivery may be the only option
• After delivery:
– Careful exam vagina for tears
– Close monitor as risk of PPH
– Careful exam of neonate (immediate and after 24 hours) to discard any
brachial plexus damage, humerus fracture or any other birth injuries
Notes:
• Never attempt to solve a shoulder dystocia alone
• Never apply fundal pressure as it will impact the shoulders into the bony
pelvis even more and can easily cause a uterine rupture
• Do NOT attempt restorage of foetal head into vagina and C-S (Zavanelli’s
manoeuvre) due to the high risk of uterine rupture

16.0 Vaginal Birth After
Caesarean Section
16.1. Definition
Vaginal delivery after previous C-S delivery
16.2. Indication
All clients with no more than 1 previous C-S that fulfil the below pre-conditions.
While it is true that there are some factors that may enhance the chances
of a successful VBAC (e.g. prior vaginal delivery or non-recurring indication
for previous CS such as a breech), any patient with previous C-S (and below
pre‑conditions) should be offered a trial of VBAC
Pre-conditions
• Patient agrees and gives written informed consent
• VBAC is performed in a CEmONC
• 1 previous C-S with transverse segmental uterine incision
• No other conditions that contraindicate vaginal birth (see below)
• Patient does not give consent
• Bemonc setting
• More than 1 previous CS
• Previous CS is confirmed or suspected not to be a transverse segmental
CS (longitudinal, transfundal or T-shaped uterine incision)
• Previous uterine rupture
• > 41 weeks
• Any other uterine scar (e.g. myomectomy)
• Any obstetric or medical condition that contraindicates vaginal birth

Uterine rupture with all its associated risks
16.5. Technique
• Monitoring of labour will follow the partograph (see Module 3)
• All clients under VBAC trial need to have: IV line, blood grouping and
crossmatching, blood/donor availability
• Monitor signs of uterine rupture: uterine tenderness, shape of uterus,
APH-PPH or foetal distress
• The timings for the second stage of labour should be cautious as the risk of
uterine rupture is higher at this stage: 2 hours maximum for primigravidas
and 1 hour for clients with previous vaginal births
In case of prolonged second stage and engaged head, assess shortening
the stage with a vacuum assisted delivery
• After delivery of the placenta check always the uterine segment to confirm
the integrity of the scar:
– A small dehiscence without bleeding requires no surgical repair if the
uterus contracts well
– A bigger dehiscence or any dehiscence associated with PPH requires
immediate laparotomy
Oxytocin and misoprostol can be used for induction and augmentation of
clients with previous C-S but with the necessary adjustment to dosages and
strict indication. See chapter on augmentation and induction of labour

17.0 Caesarean Section
The present chapter will not describe the surgical procedure which can
be found in obstetric surgery books. It focuses on the pre-, peri- and post-
operative care of C-S in MSI obstetric centres
17.1 Definition
Use of surgery to deliver the baby through an abdominal and uterine incision
The use of C-S always carries a greater risk of maternal and neonatal
morbidity and mortality than a vaginal delivery (included in informed consent)
• Classic longitudinal C-S: type of C-S in which the uterine incision is
made longitudinally in the body of the uterus. This type of C-S is no longer
in use as it has proven to have a high risk of uterine rupture in consequent
pregnancies
• Transverse lower segment C-S (also called “Misgav-Ladach C-S”): type of
C-S in which the uterine incision is made transversely through the lower
uterine segment. Currently the type of C-S used in most settings
• T-Shaped C-S: in cases of difficult extraction during C-S (e.g. obstructing
fibroids, severe oligohydramnios, prematurity) the transverse incision can
be extended to the body of the uterus in an inversed T-shape
Note that the terms transverse or longitudinal refer to the uterine incision
and NOT to the incision of the skin. A patient with a longitudinal (infra- or
supra-umbilical) skin scar may have a transverse lower segment C-S

17.2. Indication
Absolute indications:
• Severe uncontrolled APH
• Absolute CPD including malpresentations such as transverse, chin-
posterior, brow
• Uterine rupture
• ≥ 2 previous C-S
Relative indications:
• Any indication needs to be carefully weighed against risks/benefits to
mother and neonate in short, medium and long-term
• Always consider the risk of subsequent pregnancies and the reproductive
future of the client when performing a C-S
• Planned elective C-S should never be performed before 39 weeks as the
risk of neonatal respiratory distress before 39 weeks is higher regardless of
the estimated foetal weight (an exception may be a scheduled C-S for twin
pregnancy as they rarely complete 39 weeks)
• Client does not give informed consent
• Non-skilled human resources
• OT setting is not appropriate or infection prevention measures are inadequate
• Adjacent organ injury: bladder, bowel, blood vessels
• Thrombo-embolic events
• Infection
• Neonatal respiratory distress
• Uterine rupture in subsequent pregnancies

17.5. Care for uncomplicated C-S
17.5.1. Pre-operative care:
• Informed consent
• Anaesthesia evaluation
• IV line with maintenance RL/NS
• Hb, blood grouping, cross matching and ensure donors/availability of blood
• Before each procedure, critical equipment in the OT must be checked:
suction machine, electric scalpel (if present), lights, resuscitation equipment
(for neonates and adults), etc.
• Ideally the patient should have taken a shower before procedure. If this is
not possible due to emergency: change the clothes used during labour or
before arrival to a clean OT gown
• Routine prophylaxis for aspiration: cimetidine PO 200 mg in 30 ml of
water, 20 minutes before surgery OR ranitidine 150 mg PO 20 minutes
before surgery
• Routine antibiotic prophylaxis: cefazolin slow IV 2 g single dose (ideally
30-60 minutes before skin incision, but in emergency as soon as possible
before start of surgery). If antibiotics are indicated for other reasons
(e.g. PROM>24 hours) administer them as appropriate
17.5.2. Peri-operative care:

• Foley catheter
• Patient should be tilted 15º onto a left lateral position (can be supported
with a rolled towel or similar)
• Surgical skin preparation
• After extraction of baby and clamp of cord: oxythocin 10 IU slow IV or IM
injection followed by 20 IU in 1 L of RL/NS at 160 drops/minute over 2 hours
• In uncomplicated cases and newborns without distress: allow skin-to skin
contact and breastfeeding in OT while surgery is finishing

17.5.3. Postoperative care:
• First 2 hours:
– Vital signs, vaginal bleeding and uterine contraction and level of
consciousness every 15 minutes for the first hour and every 30 minutes
for the next hour
– Assist with breastfeeding and keep skin to skin contact (see below)
• Day 0:
– Monitoring: vital signs every 8 hours
– Assist and support with breastfeeding
– Analgesia:
• Tramadol IV 50 mg every 8 hours PLUS paracetamol IV 1 g every
8 hours PLUS ibuprofen 400 mg every 8 hours
• If still pain reported: morphine 10 mg every 4 hours
– Fluids: 1 L glucose 5% IV every 12 hours alternated with 1 L RL every
12 hours
– Oral intake
• If spinal anaesthesia: start slowly with oral fluids 2 hours after C-S.
Light meal can be given 6 hours after C-S
• If general anaesthesia: start slowly with oral fluids 4-6 hours after C-S.
Light meal can be given 6-12 hours after C-S
– Mobilisation
• Start early mobilisation (sitting in bed) 6 hours after C-S
– Consider thromboprophylaxis with low molecular weight heparin in high
risk patients (see Module 2)

• Day 1:
– Monitoring: vital signs per shift (8 hourly)
– Analgesia: same as D0 but all oral
– Fluids: remove IV line
– Oral intake: if well tolerated start normal diet and encourage oral fluids
– Mobilisation: patient out of bed, starts walking
– Others:
• Remove Foley catheter
• Remove dressing and advise to keep clean and dry
• Shower should be taken
• Day 2-5:
– Analgesia: remove tramadol and keep ibuprofen and paracetamol
– Encourage ambulation, normal diet
– If no complaints and the client has passed urine and stool: discharge on
D3-5
• Day 7-10: removal of stiches in OPD coinciding with third postnatal visit
(see Module 6)

17.6. Humanised C-S practice
Recent literature shows the positive effect of “humanised C-S” in terms of
better neonatal thermoregulation, increased breastfeeding rates, increased
mother-baby bonding and decreased rates of maternal depression
Humanised C-S must be the norm in all MSI centres to contribute to a
positive experience of motherhood
As far as the medical situation allows (mother with no medical conditions and
under spinal anaesthesia, no signs of foetal or neonatal distress):
• Explain in detail the indications, steps, and possible consequences of C-S.
Introduce OT team (anaesthetist, scrub and circulating nurses) to client and
birth partner
• Allow one companion or birth partner to enter the OT and accompany the
mother (on mother’s request and with explicit permission as per her birth plan)
• One of the mother’s arms will be free from IV fluids to be able to hold the
baby (leave IV line but without connecting to fluid)
• Explain each of the steps that are happening to the mother and birth partner
(e.g. “we are about to take out the baby”)
• When baby is extracted, allow for immediate skin to skin contact by
putting the baby on mother’s chest while not compromising the sterility of
the surgical field (lift surgical towel that delimits non-sterile field, put the
baby on chest and restore surgical field. Change surgical gloves in case
of need)
• Midwife and paediatrician to check, stimulate and warm baby on mother’s
chest or at least next to mother. Gynaecologist to perform delayed cord
clamping (as far the situation allows)
• While performing the surgical closure, baby will remain with mother
(and birth partner) in close skin to skin contact. Start of breastfeeding is
encouraged even while in OT
• Mother will not be separated from baby (except for logistical needs such as
transfer from OT stretcher to bed, etc.)
• Midwife will spend necessary time in recovery room, helping mother to find
an appropriate breastfeeding position (spinal anaesthesia will compromise
mother’s mobility)

In case mother is under sedation:
• Same steps as above but allow and encourage birth partner to hold baby
until mother is awake. Caretaker should ideally perform the skin to skin
contact (check acceptance and cultural values and attitudes)
• As soon mother wakes up, put baby with mother and assist for skin to skin
and early breastfeeding

18.0 Induction of Labour
18.1. Definition:
• Induction of labour: procedure by which labour is started using
pharmacological or mechanical methods
• Augmentation of labour: procedure by which contractions are stimulated
once labour has already started
18.2. Indication for induction of labour

There is a variety of medical and obstetrical indications, some of them are:
• Preeclampsia with severe features
• Eclampsia
• IUFD/stillbirth
• PROM>12 hours or signs of infection
• Post term (≥41 weeks)
Preconditions:
• CEmONC setting
• Informed consent
• Verified absence of foetal distress

18.3. Indication for augmentation of labour
Prolonged labour (including prolonged second twin expulsion) due to
dynamic dystocia
• Hyperkinesia of the uterus (> 5 contractions in 10 minutes)
• Uterine hypertonia (no relaxation between contractions)
• Uterine rupture
• Foetal distress
• PPH
• For artificial rupture of membranes (ARM): infection and cord prolapse

18.5. Methods
The below methods refer to an alive baby. Dosages for IUFD/stillbirths are slightly different, please see Module 4
Misoprostol Bishop score <6 • Preferred: 25 mcg every 2 hours oral until start of contractions
(Cervical ripening needed) OR
• 25 mcg every 6 hours vaginally until start of contractions
• Maximum dose: 200 mcg (8 doses) in 24 hours
• Do not start oxytocin until 6 hours after last dosage
Notes:
To administer 25 mcg dilute 200 mcg in 200 ml clean water and
administer 25 ml (1 mcg/ml). Keep solution for no longer than 24 hours in
closed bottle
Oxytocin • Bishop score ≥ 6 • 5 IU oxytocin in 500 ml or 10 IU in 1 L of RL or NS (10 IU/ml)
• Misoprostol not available or • Start at 5 drops/minute
contraindicated • Increase by 5 drops/minute every 30 minutes, until contractions are
• Should be used at the same effective (3 to 4 contractions of at least 40 seconds in 10 minutes)
time as artificial rupture of • Do not exceed 60 drops/minute. On average, 20 drops/minute results in
membranes to increase satisfactory uterine contractions
effectivity
• If after 12 hours of infusion and ruptured membranes the client has not
• Augmentation of labour in gone into labour: C-S
dynamic dystocia
Artificial Same as for oxytocin • Aseptic technic (sterile gloves, clean vulva and perineum)
rupture of • Dominant hand examines cervix
membranes
(amniotomy) • Non-dominant hand inserts amniohook or Kocher clamp in vagina
along to other hand and fingers
• Place 2 fingers against membranes and rupture them
• Leave the 2 fingers in the same position while liquor drains and ensure
no cord prolapse is happening
• Listen to FHR and note colour of fluid
Foley The evidence of the effectiveness • Using a sterile speculum hold the catheter size 16 or 18 with sterile
catheter of the Foley catheter is limited. forceps and introduce it through the cervix, ensuring the bulb is beyond
Its use is therefore limited to the internal os
situations in which a cervical • Inflate the bulb with 30 ml of water for injection. Coil the rest of the
ripening with misoprostol is catheter and place inside the vagina
absolutely contraindicated (e.g.
alive foetus and previous C-S with • The mother must stay lying down for one hour after insertion of catheter
unfavourable Bishop scores) • Monitor the mother’s pulse, uterine contractions, and foetal heart rate
every 30 minutes twice after insertion and then every 4 hours until
contractions start
• Leave catheter in place until contractions start or for at least 12 hours.
Deflate the bulb before removing and then proceed with oxytocin
• Do not use in cases of obvious cervicitis or vaginitis
Stripping In cases in which cervical ripening During vaginal exam, introduce finger through internal cervical os and
membranes and start of labour is wished for separate the membranes with a circular motion
(e.g. patient >40 weeks before
arriving to induction at 41 weeks)
Requires cervix to be opened
Delivery of a second twin: when contractions stop or are not enough after 15-30 minutes of the delivery of the first
twin, oxytocin infusion can be started as per protocol but increasing the infusion rate by 5 drops/min every 5 minutes

18.5.4. Monitoring
• Contractions and foetal wellbeing needs to be checked at least every
30 minutes
• Mother should be lying in left lateral position for as much time as possible
(and at least one hour after insertion of vaginal misoprostol)
• Provide analgesia according to the MSI Guidelines for Pain Management
• Partograph use is mandatory and can be started at 4 cm. Previous
monitoring during induction until 4 cm are reached needs to be recorded
in a separate sheet
18.5.5. Bishop score

Indicates the ripening of the cervix and guides in the choice of method
of induction. A cervix is considered ripe with a Bishop score of ≥ 6
0 1 2 3
Cervical dilatation
Closed 1–2 3–4 More than 5
(cm)
Cervical length (cm) More than 4 3–4 1–2 Less than 1
Cervical
Firm Medium Soft -
consistency
Cervical position Posterior Mid Anterior -
Position of the foetal

head relative to the
-3 -2 - 1, 0 + 1, + 2
ischial spines (foetal
station) (cm)
Descent by
abdominal palpation
4/5 3/5 2/5 1/5
(fifths of head
palpable)

18.6. Contraindications
18.6.1. Misoprostol should NOT be used in:
• Alive and viable foetuses and scarred uterus (including previous C-S).
Please note that in IUFD (or non-viable foetus) misoprostol can be used in
clients with previous C-S by halving the dosage (see chapter on IUFD)
• Grand multiparity (> 5 previous births)
• Overdistended uterus (twins, polyhydramnios)
In the above situations, oxytocin can be used with caution:

• Maximum rate of infusion 30 drops/min (not 60 drops/min)
• Strict interval of 30 minutes between increase in infusion rate
• Strict foetal and maternal monitoring at least every 30 minutes
18.6.2. ARM should not be performed in:

• Clients infected with HIV
• Breech presentation
• Transverse presentation
• Cord presentation
• Complete or partial placenta previa

18.7. Management of complications
Uterine • More than 4 contractions in • Stop oxytocin infusion
hyperstimulation 10 minutes • Open wide plain RL/NS
• Contractions that last longer • Lay client in left lateral
than 60 seconds position and check FHR
• No rest in between • Once uterus has relaxed
contractions oxytocin may be restarted at
10 drops/min and increased
as per protocol
• If uterus does not relax and
FHR is compromised: C-S.
Failed induction Regular contractions not • If mother’s and foetal
established or no progress in wellbeing is ensured:
cervical dilatation after: discuss with the mother the
• Maximum doses of possibility of retrying after
misoprostol been 48 hours of rest
administered • If mother or foetus
OR compromised: C-S
• 5 hours of oxytocin
Uterine rupture • Bleeding (intra-abdominal • Stop the infusion
and/or vaginal) • Call for help
• Severe abdominal pain • Emergency laparotomy
• Tender abdomen
• Clinical signs of shock
present
Foetal distress • FHR becomes irregular with • Stop the infusion
either: • Follow protocol for
– Bradycardia management of foetal
– Tachycardia compromise (see Module 3)
– Irregularities e.g.
decelerations of heart
rate that are slow to pick
up to normal rate after
the contraction

19.0 References

CC BY-NC-SA 3.0 IGO
• Pregnancy, Childbirth, Postpartum and Newborn Care A Guide for
Essential Practice - 3rd ed. World Health Organization; 2016
NC-SA 3.0 IGO
2019
• Smith, J., Plaat, F., & Fisk, N. M. (2008). The natural caesarean: a
woman-centred technique. BJOG : an international journal of obstetrics
and gynaecology, 115(8), 1037–1042. https://doi.org/10.1111/j.1471-
0528.2008.01777.x
• Windau-Melmer, Tamara. 2013. A Guide for Advocating for Respectful
Maternity Care. Washington, DC: Futures Group, Health Policy Project

Module 6
1
Antenatal Care
Postnatal Care and
Postnatal Complications
Module 6: Postnatal Care and
Postnatal Complications
The following chapter describes postnatal care for the mother. Postnatal care of the newborn is described in
Module contents
1.0 The Postnatal Period 6.2
1.1. Definition 6.2
1.2. Normal features 6.2
2.0 Recommended Postnatal Care Routine 6.3

2.1. Immediate postnatal period 6.3
2.2. First 24 hours postnatal care 6.4
2.3. S
ubsequent postnatal consultations 6.6
(D3, D7-14, week 6)
3.0 Postnatal Complications 6.7
4.0 Postnatal Contraception 6.9

4.1. Counselling 6.9
4.2. PPFP Methods 6.11
4.3. Postpartum intrauterine device (PPIUD) 6.15
5.0 References 6.29

1.0 The Postnatal Period
1.1. Definition
• Postnatal period: period that extends from delivery up to 6 weeks
postpartum. More than half of maternal deaths occur in the postnatal
period, 40% of them in the first 24 hours after delivery
• Immediate postnatal period: period between delivery of the placenta
and the first 2 hours after delivery. Also referred to as the fourth stage
of labour
1.2. Normal features

• Uterus:
– J ust after delivery: uterus is contracted just below umbilicus level
–D
uring the first 5 days: uterus contracts each day around 1 cm which is
approximately 1 finger diameter below the umbilicus each day. At day 5
postpartum it should be between umbilicus and symphysis pubis
–D
ay 10 postpartum: uterus is at symphysis pubis and cervix is closed
–W
eek 6: uterus has recovered its normal size
• Bleeding/Lochia:
–B
leeding is moderate to heavy during the first 3 days and starts decreasing
progressively. Lochia become blood stained and are odourless
–B
leeding usually stops between 2-3 weeks postpartum
–F
irst menstrual period iin clients that are not breastfeeding happens
6-8 weeks postpartum
• Breastfeeding:
–D
ay 0-2 postpartum: secretion of colostrum, a yellowish secretion in
small quantity which is highly caloric
–D
ay 3-5: first days of breastmilk production accompanied by breast
tenderness and possible febricula (<38º). Milk is white in colour and in
higher quantities

2.0 R
ecommended Postnatal
Care Routine
The postnatal period requires specific monitoring for mother and newborn:
• Close monitoring in the immediate postnatal period (first 2 hours after
delivery)
• Admission in the health facility for 24 hours for all mothers and newborns
after a normal uneventful vaginal delivery
• At least 4 postnatal check-ups in the first 6 weeks:
–D
1: during admission and upon discharge
–D
3: for C-S the check-up will be done while admitted. For normal
deliveries that were already discharged it is advisable that the client
attends a follow up visit. Home visits performed by a skilled attendant
are a valid alternative
– D7-14: outpatient follow up
–W
eek 6: outpatient follow up
2.1. Immediate postnatal period

• Requires special attention as the majority of PPH occur during the first 2
hours after delivery
• Monitoring of mother: vital signs (BP, pulse, RR and temperature), uterine
contraction, and vaginal bleeding every 15 min the first hour and every 30
min the second hour
• Monitoring of baby: HR, temperature and RR every 30 min the first 2
hours of life
• Encourage and support mother-to-baby skin-to-skin contact and early
breastfeeding
• Encourage passing urine
• For the baby within the first hour of life provide essential and routine
neonatal care (see Module 7)

2.2. First 24 hours postnatal care
• For postnatal care in C-S see Module 5
• After an uncomplicated vaginal birth in a health facility, healthy mothers and
newborns should receive care in the facility for at least 24 hours following
the birth
If this is not possible for any kind of reason: arrange for home visit or at
least follow up by phone
• Client-centred and respectful postnatal care includes rooming (avoiding
separation mother-newborn unless medical conditions do not allow it)
• There is no evidence of the need of prophylactic postpartum antibiotics in
an uneventful vaginal delivery.
• Counsel for postpartum contraception if it was not done or decided previously
• During the first 24 hours following the birth, all clients will be monitored for:
–V
aginal bleeding
–U
terine contraction and fundal height
–E
pisiotomy/perineal tear healing
–T
emperature and heart rate
–V
ital signs every 6-8 hours
–S
igns of anaemia
–U
rine void should be documented within 6 hours of birth
–B
reastfeeding
–E
motional wellbeing
–E
arly mobilisation

• On discharge:
– Iron-folate supplementation as per ANC for the next 3 months
– If pain: paracetamol 1 g/6 hours or ibuprofen 400 mg/6 hours
–P
rovide appointment for follow up visits, postnatal card, and baby’s
vaccination card
–P
rovide information on:
• Appropriate perineal hygiene: daily cleaning with soap and water,
frequent change of pads and keeping dry
• Danger signs for mother: visual disturbances, headache, seizures,
excessive bleeding, foul-smelling discharge, fever, emotional
instability, etc.
• Danger signs for the baby (see Module 7)
• Delay of sexual intercourse, at least until lochia are no longer stained
with blood
• Birth spacing and contraception options: if not yet discussed or
decision taken
• Pelvic floor exercises

2.3. Subsequent postnatal consultations
(D3, D7-14, week 6)
2.3.1. In all postnatal visits assess mother for:
• General well-being, urination and urinary incontinence, bowel function,
healing of any perineal wound, headache, fatigue, back pain, perineal
pain and perineal hygiene, breastfeeding and breast pain, uterine
tenderness, and lochia
• Emotional wellbeing, family, and social support (including any signs of
intimate partner violence)
• Visit at week 6: perform speculum (and pap smear if available).
Inform about possible dyspareunia, safe sex, contraception
2.3.2. In all postnatal visits assess baby for:

• Vital signs
• Weight/height
• Cord care: soap and water and dry
• Any danger signs that need referral (see Module 7)
• Routine vaccination and vitamin D supplements
2.3.3. Inform mother about:

• Birth spacing and contraception, safe sex and use of condoms (if not
done already)
• Signs of wellbeing for the mother and the infant
• Resumption of sexual intercourse and possible dyspareunia (week 6)
• Advice on malaria prevention (sleep under ITN for mother and newborn)
• Advice on nutrition and maintain iron-folic supplements for 3 months
postpartum
Offer additional supportive care in form of postnatal support groups

3.0 Postnatal Complications
The following table summarises the most frequent postpartum

complications, their differential diagnoses and management
Complication Diagnosis Management

PPH (see • Excessive uterine bleeding +/-foul smelling • Digital curettage, MVA, D&C
Module 5) lochia, uterus soft/painful/high • Antibiotics:
- Ambulatory: amoxicillin-clavulanic acid 875/125mg
every 8h PO for 5 days
- Admission: see below
Endometritis/ • High fever Admission:
Abdominal • Painful abdomen, pelvic pain, foul smelling, or • Amoxicillin-clavulanic acid IV 1000/200 mg every 8
abscess/ purulent vaginal discharge hours AND gentamycin 5 mg/kg/24h
Puerperal • Uterus soft and enlarged, painful on OR
sepsis examination • Ampicillin 2 gr/8 hours IV AND metronidazole 500 mg
• Signs of PID: pain on cervical motion on every 8 hours IV/IM AND gentamycin 5 mg/kg every
bimanual exam 24 hours
• Signs and symptoms of septic shock (hyper- • IV antibiotics for 48 hours after fever resolution and
hypothermia, low BP, high pulse, bad general change to oral (see above)
condition) • Paracetamol 1 g every 6-8 hours (IV or PO depending
on fever and pain)
• Assess need of MVA, digital curettage or D&C after
24 hours of starting antibiotics
• If septic shock: fluids up to 6 L / 24 h + O2 8 L /min
• If abdominal or pelvic abscess suspected (fever
maintained, suggestive US): laparotomy after 24 hours
IV AB
Mastitis • Breasts with red, warm and swollen area • Encourage mother to continue breastfeeding and empty
• Pain well the affected breast
• Fever, chills • Analgesia: paracetamol or ibuprofen
• Usually accompanied by breast engorgement • Cloxacillin 1 g PO every 8 hours for 7 days
• Sometimes purulent discharge from nipple or • If abscess: drainage in OT
fluctuating abscess
• Axillar lymph nodes can be enlarged

Complication Diagnosis Management
Faecal • Stool incontinence, with or without relationship Refer for specialised management
incontinence to increase abdominal pressure
• History of 4th degree tear or obstructed labour
(rectovaginal fistula)
• Recto-vaginal fistula: hole that connects vagina
and rectum. Can be seen with speculum and
when introducing gloved finger in rectum
• Incontinence of anal sphincter: absence of
fistula. On rectal digital exam there is no tonus
on anal sphincter
Infection of • Swollen, red, warm and painful area around the • Amoxicillin-clavulanic acid 875/125 mg every 8 hours PO
episiotomy/ stiches of the suture for 7 days
perineal suture • Purulent discharge • Pain management with paracetamol or ibuprofen.
• Sometimes fever • Advice on hygiene: clean every 12 hours with soap and
water and keep very dry.
• If purulent discharge: remove some stiches to allow
drainage. Closure should happen on secondary intention
(through spontaneous granulation of tissue). If the
dehiscence is big, wait until no signs of infection and re-
suture in OT after refreshment of wound borders.
Postpartum • Sadness, loss of confidence and self-esteem, Refer to specialists for anti-depressant medication and
depression feelings of guilt or incompetence, no desire to monitoring.
take care of baby, frequent unexplained crying,
etc. for more than 2 weeks during postpartum.
• Suicidal thoughts in extreme cases
• Hallucination and delusions in psychotic
disorders

4.0 P
ostnatal Contraception
4.1. Counselling
All providers counselling clients in post-partum contraception/family
planning (PPFP) must be aware of and familiar with the MSI Guidelines for
Client Counselling and Informed Consent
4.1.1. When to counsel:

• During the ANC (last visits): allows the client time to consider which
method they prefer. Wherever possible gives the client time to consider
the choice of methods offered and make an informed decision. Wherever
possible (and with client’s consent) counselling can be conducted jointly
with the partner or other family member
• During postnatal period: if not decided or approached during ANC,
the client needs to be counselled on PPFP on D1 postnatal period.
If no decision has been taken, re-counselling should be offered in the
subsequent follow up checks
• The client should not be counselled for the first time about PPFP during
labour or immediate postnatal period (first 2 hours after childbirth) as they
may not be able to make an informed choice

4.1.2. Points to consider when counselling on PPFP
Return to fertility There is no set time for the “return to fertility.” When a client can fall pregnant again depends on the
combined effect of breastfeeding practices, return of menses, sexual activity and use of contraceptive
methods
Breastfeeding status Choice and options for family planning vary based on the client’s breastfeeding status and the number
of months that have passed after the birth. Clients should be counselled on types of methods that do not
affect breastfeeding or breast milk and when/how to start them
Postpartum Postpartum amenorrhoea, i.e. the length of time a postpartum client goes without menses after giving
amenorrhoea birth, varies. While menses return is one marker of being fertile again, postpartum clients may still get
pregnant before their monthly bleeding returns. Clients need to be informed about the importance of
starting a contraceptive method before their menses returns
Lactational A LAM user will need to switch to another method when:
amenorrhoea method • Menses return
(LAM) users
• The baby does not only consume breastmilk (start of complementary feeding)
• Baby is >6 months old
• Client would prefer to use a contraceptive method other than LAM
Counselling clients on LAM increases uptake of other contraceptive methods
Postpartum In some cultures, postpartum abstinence (period of time during which postpartum clients should avoid
abstinence and return sex) is common. Although this practice is changing, it might be assumed that postpartum clients are not
to having sex having sex for a long period of time after childbirth, and thus not in need of a contraception. Providers
need to take a non-judgmental and sensitive approach to counselling in cultures where this view is still
considered the norm
Limited mobility Some cultures limit new mothers from leaving the home during the first few weeks postpartum. This can
and access to affect their ease of accessing contraception. Therefore, it is better to counsel clients in the antenatal
services during the period about the method options that are available. Methods can be given immediately after birth
postpartum period even if the client plans to start them later on (e.g. giving COC to breastfeeding clients for use after
breastfeeding)
Decision-making In many cases, postpartum clients are not the only decision-makers about their own use of methods
or services. Partners and other family members may need to be included in the counselling of
contraception use. Of course, the final decision on contraceptive methods must be the client’s choice
and no one else’s
During infant Postnatal infant visits (e.g. vaccination) are an ideal timing to ask the client if contraception is needed,
postnatal visits and offer counselling on options and alternatives

4.2. PPFP Methods
Please refer to the method-specific MSI guidelines for information on the
various contraceptive methods. Some points on their start during postnatal
period can be found in the following job aids. PPFP with intrauterine device
(IUD) is described in Section 4.3
Method options for non-breastfeeding clients
Can be used • Condoms

immediately • Progestin-only oral contraceptives
postpartum
• Progestin-only injectables
• Implant
• Spermicide
• Tubal ligation (within 7 days or delay 6 weeks)
• Copper IUD (immediately following expulsion of placenta
or within 48 hours)
Delay 3 weeks • Combined oral contraceptives (without other risk factors
for VTE)
• Combined injectables
• Fertility awareness methods
Delay 6 weeks • Diaphragm
• Clients with risk factors for VTE: previous VTE,
thrombophilia, caesarean delivery, blood transfusion
at delivery, postpartum haemorrhage, pre-eclampsia,
obesity (≥30 kg/m2), smoking, and being bedridden for a
prolonged time

Method options for breastfeeding clients
Can be used • LAM

immediately • Condoms
postpartum
• Spermicide
• Tubal ligation (within 7 days or delay 6 weeks)
• Copper and LNG IUD (within 48 hours or delay 4 weeks)
• Progestin-only oral contraceptives
• Contraceptive implant
Delay 6 weeks • Progestin-only injectables
Delay 6 months • Combined oral contraceptives

• Combined injectables
• Fertility awareness methods

Figure 1. Job aid on initiation of different contraceptive methods during postnatal period
Delivery 48 hr 7 days 3 weeks 4 weeks 6 weeks 6 months 9 months
CONDOMS/SPERMICIDES
IUD
TUBAL LIGATION
All clients
EMERGENCY CONTRACEPTION
VASECTOMY

Breastfeeding clients
LACTATIONAL AMENORRHOEA METHOD
PROGESTIN ONLY PILLS AND IMPLANTS
COMBINED
PROGESTIN-ONLY INJECTABLES

Non-breastfeeding clients
PROGESTIN-ONLY METHODS
COMBINED ESTROGEN-PROGESTIN (INJECTABLES AND ORAL)

Table 1. Initiation of contraceptive methods after birth
Non-breastfeeding Breastfeeding
Copper or LNG IUD Within 48 hours, or from at least 4 weeks after Within 48 hours, or from at least 4 weeks after
childbirth childbirth
Combined pill 3 weeks after childbirth 6 months after childbirth
Progestin pill Immediately after childbirth Immediately postpartum
Progestin only Immediately after childbirth 6 weeks after childbirth

injectable
Progestin implant Immediately after childbirth Immediately after childbirth
Tubal ligation Within 7 days, or from 6 weeks after childbirth Within 7 days, or from 6 weeks after childbirth
Male and female Immediately after childbirth Immediately after childbirth

condoms
LAM NA Start immediately after childbirth; can use for up to

6 months

4.3. Postpartum intrauterine device (PPIUD)
4.3.1. Definition
There are three types of PPIUD depending on the time of insertion:
• Post-placental: Immediately following the delivery of the placenta,
the IUD is inserted within 10 minutes from the time the placenta was
delivered
• Intra-caesarean: Immediately following the removal of the placenta
during a caesarean section, the IUD is inserted manually before closure
of the uterine incision
• Early postpartum: Not immediately following the delivery/removal of
the placenta, but the IUD is inserted within 48 hours of the birth (and
preferably within 24 hours)
Common IUD used for PPFP are the copper IUD (CuT380A and Cu 75)
and levonorgestrel intrauterine system (LNG-IUS)

4.3.2. Indications and eligibility
The IUD should not be inserted between 48 hours and 4 weeks postpartum
because of higher rates of expulsion
IUDs inserted at 4 weeks postpartum and beyond are considered interval
IUDs, rather than PPIUDs, as the insertion technique is the same as in
non‑postpartum clients
Eligibility criteria for PPIUD follow WHO Medical Eligibility Criteria (MEC):
Category With clinical judgement With limited clinical judgement
1 Use method in any circumstance Yes (use the method)
2 Generally, use the method
3 Use of method not usually No (do not use the method)

recommended unless other more
appropriate methods are not
available or not acceptable
4 Method not to be used
• Category 3 and 4 conditions for PPIUD are listed below and any of them
will mean that the client is not eligible for PPIUD
• Counselling and screening should be done in two stages: one during
ANC period (first screening) and a second one repeated just prior to
insertion (second screening)

4.3.3. First screening
Category 3 conditions Category 4 conditions

Generally do not use the method unless Do not use method
more appropriate methods are not
available or acceptable
• Severe or advanced HIV clinical • Pregnancy (known or suspected)
disease and AIDS without antiretroviral • Unexplained vaginal bleeding
therapy
• Current PID, gonorrhoea or chlamydia
• Very high individual risk of chlamydia
or gonococcal infection (partner has • Acute purulent (pus-like) discharge
current purulent discharge or STI) • Distorted uterine cavity
• Ovarian cancer • Malignant or benign trophoblast
• Benign trophoblastic disease disease
• Lupus with severe thrombocytopenia • Known pelvic tuberculosis

• Genital tract cancer (cervical or
endometrial)
4.3.4. Second screening

The conditions listed below are contraindications that need to be checked
post-delivery, prior to insertion. Presence of any of these contraindicates
the use of PPIUD as a PPFP method
• Chorioamnionitis
• Extensive genital trauma where insertion may disrupt the repair
[Note: This only applies to insertion on postpartum Day 1 or 2]
• Postpartum endometritis
• Current PID, gonorrhoea, or chlamydia
• Prolonged rupture of membranes, PROM > 18 hours only for post-
placental insertion
• For early PPIUD, if PROM was appropriately treated with antibiotics and
the patient has no signs of infection in immediate postpartum, the IUD
can be inserted without problem

4.3.5. Advantages/disadvantages of PPIUD
Advantages for the client Limitations
Convenience, saves time and additional visits Increased risk of spontaneous

expulsion as compared to interval
IUD. Skilled provider and correct
technique lowers significantly
expulsion rates
Safe because it is certain that the client is not The other limitations of the PPIUD
pregnant at time of insertion are the same as the interval IUD
A very reliable birth spacing method
Has very little risk of uterine perforation

because of the thick wall of the uterus in
postpartum period
Reduced perception of side effects (bleeding
and cramping are experienced during
postpartum anyway)
Reduced chance of heavy bleeding among
clients who are exclusively breastfeeding
and in first 6 months PP, since they are
experiencing amenorrhea
No effect on breastfeeding
The client has an effective method for

contraception before discharge from hospital

4.3.6. Risks/complications
• Expulsion: can be minimised if the timing is respected (never > 48 hours
postpartum) and the insertion is done by a skilled provider
• Infection
• Perforation
• Coercion is a possibility if method counselling takes place during delivery
4.3.7. Material required
List of instruments needed for PPIUD
Table/tray for equipment

Long placental forceps/ Kellys forceps 33 cm
Ring forceps for gripping the cervix
Retractor or Simms speculum
Gauze/cotton for cleaning cervix and vagina x2
Antiseptic solution
Sterile gloves
IUD in sterile packet

4.3.8. Post-placental insertion technique
The insertion should take place within 10 minutes of delivery of the
placenta. The whole procedure should not take longer than 5 minutes
✔ Confirm that the client still wants that PPIUD, that a second screening
has taken place (see previous section), and that written informed
consent has been taken
✔ Throughout the whole procedure the provider keeps the client informed
of the current steps and the steps ahead
✔ ATMSL is finalised
✔ Assess need for additional analgesia
✔ Use a new pair of sterile gloves
✔ Open PPIUD kit and arrange instruments in a sterile field, place dry
sterile cloth on client’s abdomen
✔ Gently insert Simms speculum and visualise the cervix by depressing
the posterior wall of the vagina; gentle fundal pressure can be applied
(by an assistant or with the other hand on sterile drape over abdomen) to
make the cervix descend
✔ Clean the cervix and vagina with antiseptic solution two times using two
separate gauzes
✔ G
ently grasp the anterior lip of cervix with the ring forceps. The speculum
may be removed at this point
✔ Open sterile package of IUD from the bottom by pulling back plastic
cover approximately one-third upwards and remove plunger rod, inserter
tube and card from package
✔ With the long Kelly forceps, grasp the right arm and vertical stem of the
IUD inside the sterile package, careful not to entangle the strings in the
forceps
✔ Gently lift anterior lip of the cervix using the ring forceps
✔ Gently insert and slowly advance the IUD:
– Insert Kelly forceps holding the IUD through the cervix into lower
uterine cavity without touching vaginal walls
– Gently move IUD further into the uterus until a point with slight
resistance is felt (posterior wall of lower uterine segment)

–L
ower the ring forceps and remove it from cervix while keeping Kelly
forceps firmly closed
✔ Elevate the uterus by placing base of the non-dominant hand on the
lower part of the uterus (midline, just above symphysis pubis with the
fingers towards the fundus) and push gently upwards to extend the
lower uterine segment
✔ Move the Kelly forceps with the IUD towards the client’s umbilicus to
reach the uterine fundus. For this step it is helpful to lower the hand
holding the Kelly forceps to surpass the vagino-uterine angle and follow
the contour of the uterus
✔ Gently advance the forceps until the resistance of the uterine fundus is
felt. This will be confirmed by feeling the uterus through the abdominal
wall. The handle of the Kelly forceps should be at or very close to the
client’s perineum
✔ While continuing to stabilise the uterus with the abdominal hand, open
Kelly forceps slowly, tilting them slightly towards the midline to release
the IUD at the uterine fundus
✔ Keep the forceps slightly open and sweep them to the sidewall of the
uterus. Slide them alongside the wall to remove them from uterine
cavity. Be careful not to dislodge the IUD or catch the strings. Do not
stop stabilising the uterus until the forceps are completely removed
✔ Examine cervix: no strings of the IUD should be visible. If they are:
remove IUD, put in sterile package, inform the client and proceed to
reinsertion
✔ Review any bleeding from cervix due to the initial forceps and proceed
with the suturing of episiotomy/lacerations if any
✔ Proceed with routine postpartum care and record the procedure. Give
the IUD card to the client
It is possible to perform a post-placental insertion with the hand instead of
with the Kelly forceps. The steps are the same as above but with the index
and middle finger of the dominant hand holding the vertical rod of the IUD

(Pictures reproduced from Postpartum Intrauterine Device (PPIUD) Services: A Reference Manual for Providers, Jhpiego, 2010)

4.3.9. Early postpartum insertion
The technique is identical to the one outlined in post-placental insertion
with few differences and notes of caution:
• Ideally insert IUD in the first 24 hours postpartum (maximum limit: 48
hours)
• Manual insertion will not be possible as cervix has started to close and
uterus to contract
• In some cases the cervix has already closed so much that it does not
allow easy insertion of the distal ring of the Kelly forceps. Use a normal
ring forceps and apply extra fundal pressure to allow the uterus to
descend and the (“normal”) ring forceps to reach fundus.
• As the uterus has contracted greatly and started to retrovert or antevert
again, extra caution must be put to reach adequately the uterine fundus to
avoid expulsion. After insertion, IUD strings should not be visible (or only
their tip)

4.3.10. Intra-caesarean IUD
• Confirm that the client still wants the PPIUD, a second screening has
taken place (see previous section), and that written informed consent has
been recorded
• Throughout the whole procedure the provider should keep the client
informed of the current steps and the steps ahead
• ATMSL is finalised but no uterine closure
• Use a new pair of sterile gloves
• Open PPIUD kit and arrange instruments in a sterile field
• If client is under spinal anaesthesia, inform them when the IUD is being
placed
• Hold IUD at the end of vertical rod with index and middle finger or with a
forceps by grasping right arm and vertical vest.
• Stabilise uterus by holding the fundus with the non-dominant hand
• Insert IUD with dominant hand through the uterine incision and move
towards the fundus
• Release IUD and gently remove hand without dislodging the IUD
• Point the IUD strings towards the uterine segment but do not push them
through the cervix (as it could pull the IUD from the fundal position)
• Close uterine incision without catching accidentally the strings in the
suture

4.3.11. Advice on discharge (post-insertion)
• Be aware that the postpartum symptoms, such as intermittent vaginal
bleeding and cramping are normal for the first 4 to 6 weeks postpartum
and may be hard to distinguish from IUD side effects
• Take ibuprofen, paracetamol or other pain reliever as advised on
discharge
• Breastfeeding should start/continue. There is no interference with IUD
• Remember that the IUD does not protect against STIs and HIV
• Resume intercourse at any time client feels ready. The IUD offers full
protection against pregnancy immediately upon insertion
• Follow-up visit is recommended at 4-6 weeks following IUD insertion
(provide client with IUD card)
• Regarding possible IUD expulsion:
– Spontaneous expulsion is most likely to occur during the first 3 months
– Advise client to check the bed sheets in the morning and
undergarments when changing clothes during these first 3 months
– At 6 weeks postpartum, client (or partner) may be able to feel the
strings. It is not necessary to check for them, if the client does, advise
that they should not be pulled on
• Warning signs and when to contact emergency services:
– Heavy vaginal bleeding
– Severe lower abdominal discomfort
– Fever
– Not feeling well
– Foul smelling vaginal discharge (different from lochia)
– Signs of pregnancy
– Concerns that the IUD has fallen out

4.3.12. Management of side effects and complications
Side effect or complication Management
Changes in menstrual bleeding patterns, • Determine severity, length and start of symptoms
pain or cramping • Are they accompanied by other symptoms (e.g. fever)?
• Increase in amount and duration of • How well iis the client tolerating them?
menstrual bleeding/pain above what is
usually expected in the postpartum period • Rule out other gynaecologic pathology and refer client to a qualified practitioner,
if indicated
• Spotting/light bleeding between periods
once they resume • Where appropriate, rule out pregnancy
• Check for IUD expulsion by palpating strings on bimanual exam, by using a
speculum or in case of doubt with an US
• If symptoms are mild and consistent with uterine involution, provide reassurance
• If client desires treatment, offer a short course of NSAIDs, continued for 3 to 5
days
• If bleeding is persistently heavy and prolonged or associated with clinical or
laboratory signs consistent with severe anaemia (e.g. pallor, weakness), offer iron
replacement therapy. Consider IUD removal with the client’s consent
• If client finds bleeding or pain unacceptable, remove IUD and counsel on
alternative methods of contraception
Infection: • Perform a full examination, including: vital signs, abdominal and pelvic
• Lower abdominal pain examination and appropriate studies (pregnancy test, full blood count, midstream
urinary analysis and culture and US) to rule out endometritis, appendicitis, partial
• Fever IUD expulsion, uterine perforation, pregnancy/ectopic pregnancy or urinary tract
• Painful intercourse infection. If appropriate, see section for management of pregnancy with the IUD
in place.
• Bleeding after intercourse or between
periods once resumption of normal monthly • Suspect PID if any of the following signs/symptoms are found and no other causes
menses has occurred can be identified:
• New onset of pain associated with periods – Lower abdominal, uterine or adnexal tenderness (tenderness in the ovaries or
fallopian tubes)
• Abnormal vaginal discharge
– Evidence of cervical infection: yellow cervical discharge containing mucus and
pus, cervical bleeding when it is touched, positive swab test
– Tenderness or pain when moving the cervix and uterus during bimanual exam
(cervical motion tenderness)
– Other possible sign/symptoms: purulent cervical discharge, enlargement or
hardening (in duration) of one or both fallopian tubes, a tender pelvic mass, pain
when the abdomen is gently pressed (direct abdominal tenderness) or when
gently pressed and then suddenly released (rebound abdominal tenderness)
• If endometritis or PID is suspected, begin treatment immediately with an
appropriate antibiotic regimen per global standards/local protocols for gonorrhoea,
chlamydia and anaerobic infections. Remove the IUD only in the presence of
sepsis or if symptoms do not improve within 72 hours. Studies have not indicated
that removing the IUD affects outcomes of PID treatment
• If the client does not want to keep the IUD in during treatment, remove the IUD 2-3
days after antibiotic treatment has begun
• Where appropriate and when an STI is suspected, counsel the client regarding
condom use for protection against future STIs and recommend treatment for the
partner

IUD strings are missing • Rule out pregnancy by history or laboratory examination
• Probe the cervical canal using an sterile cervical brush or narrow forceps (e.g.
Bose, alligator) to locate the strings and gently draw them out so that they are
protruding into the vaginal canal
– If the strings are not located in the cervical canal, refer the client for an
ultrasound to confirm normal intrauterine positioning. If US is not available
X-ray is advised. Provide a back-up method while waiting for results. Manage
as appropriate based on findings:
• If the IUD is located inside the uterus and the client wants to keep the IUD,
do not remove it. Explain to the client that the IUD is still protecting against
pregnancy but that they will no longer be able to feel the strings. Review
signs and symptoms of spontaneous expulsion
• If the IUD is located inside the uterus and the client wants it removed, ensure
IUD removal by a specially trained provider
• If the IUD cannot be visualised in the uterus or the peritoneal cavity, manage
as complete IUD expulsion (below)
Long/short strings Trim strings as needed, up to 3 – 4 cm from cervical os.
• Reassure the client and partner that the strings are very flexible and not harmful
• If long strings are bothersome, advise the client that IUD strings can be cut
shorter, so that the string curves around the cervical lip. Trim as needed
• If short strings are bothersome for the client or their partner, cut them up to the
level of the cervical canal
Partial or complete IUD expulsion Conduct an appropriate assessment, including pelvic examination to rule out other
• New onset of irregular bleeding and/or possible causes of symptoms such as infection and pregnancy.
cramping • If complete expulsion of the IUD is confirmed (e.g. seen by the client, confirmed
• Expelled IUD seen in complete expulsion by US or X-ray) replace IUD immediately, if desired and appropriate (not
pregnant or infected), or counsel for alternative family planning method
• IUCD felt/seen in the vaginal canal (partial
expulsion) • If partial IUD expulsion is confirmed (e.g. felt/seen by the client or clinician)
remove the IUD and replace it, if desired and appropriate
• Delayed or missed menstrual period (See
Pregnancy with an IUD in Place, below) • If the IUD appears to be embedded in the cervical canal and cannot be easily
removed in the standard fashion, ensure removal of IUD by a specially trained
• Missing or longer strings provider (for details IUD removal guidance, please see MSI Guidelines for IUD
and IUS Contraceptives)
• If complete expulsion of the IUD is confirmed and pregnancy diagnosed,
manage ANC per MSI standards, see below

Pregnancy with an IUD in place • Confirm pregnancy and trimester. If the client is in the second or third trimester of
• Delayed or missed menstrual period pregnancy, manage according to MSI guidelines
• Other signs/symptoms of pregnancy • Rule out ectopic pregnancy. If ectopic pregnancy is suspected, immediately refer
the client to a facility with surgical capability
• Missing strings
• If the pregnancy is in the first trimester:
• Strings that are shorter or longer than
expected – C
ounsel the client on the benefits and risks of immediate removal of the IUD.
Removing the IUD slightly increases the risk of miscarriage; leaving the IUD in
place can cause second trimester miscarriage, infection and preterm delivery
– If the client requests removal, proceed with immediate removal if the strings
are visible and the pregnancy is in the first trimester. If the strings are not
visible, do an ultrasound to determine whether the IUD is still in the uterus
or has been expelled. If the IUD is still in place, it cannot be safely removed.
Follow, as below, with plans to remove the IUD at delivery
– If the client declines removal, provide support and care per standard MSI
global guidelines and arrange close monitoring of the pregnancy. Stress the
importance of returning to the clinic immediately if they experience signs of
spontaneous abortion or infection (e.g. fever, low abdominal pain, and/or
bleeding) or any other warning signs. Plan to remove the IUD at delivery

5.0 References
• World Health Organization. Postnatal care for mothers and newborns.

Highlights from the World Health Organization 2013 Guidelines [Internet].
WHO; (Maternal and Child survival program). Available from: https://www.
who.int/maternal_child_adolescent/publications/WHO-MCA-PNC-2014-
Briefer_A4.pdf?ua=1
• World Health Organization. WHO recommendations on postnatal care of the
mother and newborn. 2013.https://apps.who.int/iris/bitstream/
handle/10665/97603/9789241506649_eng.pdf?sequence=1
• World Health Organization. Managing Complications in Pregnancy and
Childbirth, 2017. https://apps.who.int/iris/bitstream/hand
le/10665/255760/9789241565493-eng.
pdf;jsessionid=28797ACA5A26CA683EAD63F667EA7107?sequence=1
2019.
• World Health Organization, Reproductive Health and Research, K4Health.
Family planning: a global handbook for providers : evidence-based guidance
developed through worldwide collaboration. [Internet]. Geneva]; Baltimore:
World Health Organization, Department of Reproductive Health and
Research ; John Hopkins Bloomberg School of Public Health, Center for
Communication programs, Knowledge for Health Project; 2018 [cited 2020
Oct 12]. Available from: http://apps.who.int/iris/bitstre
am/10665/260156/1/9780999203705-eng.pdf?ua=1
• 5th Edition Medical eligibility criteria for contraceptive use, WHO, 2015.
• Postpartum Intrauterine Device (PPIUD) Services: A Reference Manual for
Providers Jhpiego, 2010
• Postpartum IUCD curriculum Marie Stopes International and USAID(2013)
• Postpartum IUD insertion: PSI http://www.psi.org/program/post-partum- iud-
insertion

Module 7
1
AntenatalCare
Newborn Care
Module contents
1.0 Essential Newborn Care 7.2 3.0 Care of Sick Newborns 7.18
1.1 Definition 7.2 3.1 General danger signs 7.18
1.2 Immediate newborn care 7.2 3.2 Neonatal infection 7.19
1.3 Routine newborn care: 7.5 3.3 Jaundice 7.21
90 minutes to 24 hours after birth 3.4 Convulsions 7.23
1.4 Routine newborn care: 7.11 3.5 Cyanosis or difficult breathing 7.24
from discharge to 6 weeks
3.6 Lethargy 7.24
postnatal period
3.7 Hypothermia and hyperthermia 7.25
2.0 Newborn Resuscitation 7.12 3.8 Hypoglycaemia 7.26
2.1 Equipment 7.12
4.0 Care of Preterm and Low Birth Weight 7.28
2.2 Neonatal resuscitation algorithm 7.13
Newborns
2.3 Basic resuscitation 7.14
4.1 Risks/Complications 7.28
2.4 Post-resuscitation care 7.17
4.2 Management 7.28
5.0 References 7.32
V1.0 MSI Reproductive Choices Module 7: Newborn Care 7.1

1.0 Essential Newborn Care
The present chapter describes the essential newborn care including

neonatal resuscitation during the first hours of life. Management of the
most frequent neonatal complications and general measures for preterm
and low birth weight babies are included, however they are not meant
to replace specialised neonatal guidelines
1.1 Definition
Essential newborn care (ENC) is the standard basic care that all
babies should receive at birth. It includes:
• Immediate newborn care: care provided during the first minute
of life (called the “golden minute”) and up to 90 minutes after birth
• Routine newborn care: care provided after the first 90 minutes of life
1.2 Immediate newborn care

• Immediate newborn care aims to identify baby’s in need of neonatal
resuscitation and further care for urgent conditions as well as to provide
preventive life-saving measures
• The first minute of life (“golden minute”) is especially time-sensitive
to start newborn resuscitation
• Equipment for immediate newborn care and resuscitation needs
to be prepared for all deliveries before the birth

During the first 30 seconds
• Deliver the baby on a dry cloth on mother’s abdomen
• Dry the baby vigorously
• Check the breathing while drying
GOLDEN MINUTE
Is baby breathing and/or crying?
YES NO
Following 30 seconds:
Routine care. See below BASIC RESUSCITATION
See neonatal resuscitation
Routine care during the next 5 minutes:

• Change the wet cloth for a new dry one and put baby skin-to-skin with mother. Cover both with
a new dry and clean cloth and blanket. Cover baby’s head
Skin-to-skin contact will effectively regulate baby’s heat and breathing
• Perform AMTSL as per protocol
• After 1-3 minutes, clamp the cord when it stops pulsating with 2 Kocher forceps at around 10
cm from umbilicus. Use a sterile new scissor (different from the one used for episiotomy). Tie off
the cord with a Barr clamp (or sterile threat) leaving a 2-3 cm stump
• Perform Apgar test (can be done on mother)
• Continue skin to skin care and monitor baby´s breathing. Do NOT separate the baby from the
mother (skin-to-skin) unless respiratory distress is detected or maternal emergency
During the first 90 minutes:

• Continue skin to skin care and monitor baby´s breathing every 30 min during the first 2 hours
postpartum. Do not separate the baby from the mother (skin-to-skin) unless respiratory distress
is detected or maternal emergency
• Help to start breastfeeding by positioning the baby nearby mother´s breast able to latch
(usually baby is ready between 15-60 minutes after birth)
• Perform a complete routine examination including weight (see below). Ideally this should be
done after the baby has breastfed for the first time and after 60 minutes of skin-to-skin contact.
Identify babies with danger signs or babies that need resuscitation
• Provide eye care with 1% tetracycline eye ointment on the lower eyelid (ideally in the first 60
minutes of life)
• Provide cord care: apply chlorhexidine 4% solution to the cord stump once (single application at
birth that does not require to be repeated during postnatal period)
• Give vitamin K: 1 mg vitamin K IM for babies >1500 g and 0.5 mg for babies <1500 g (can be
given up to 24 hours after birth)
• Do not bath the baby for the first 24 hours (to allow the baby to retain heat). If culturally not
possible delay at least for 6 hours
• Document all the above and issue birth registration/certificate

1.2.1 Apgar score
• The Apgar score is a tool for monitoring how the neonate adapts
to extra-uterine life during the first minutes
• It is usually done at minute 1 and 5. Apgar scores at 10 minutes
are done when the score after 5 minutes is < 7
• An Apgar score < 5 at 1 minute and < 7 at 5 minutes requires
immediate call to a paediatrician
• In cases where the baby needs resuscitation, the Apgar score can
be done retrospectively
Apgar score at 1 minute Apgar score at 5 minutes
0-4: Birth asphyxia. Requires newborn

• 0-6: Birth asphyxia. Requires newborn
•
resuscitation resuscitation
5-7: Difficult adaptation.
• 7-8: Difficult adaptation.
•
Requires intensive monitoring Requires intensive monitoring
and continuous stimulation and continuous stimulation
8-10: Good adaptation
• 9-10: Good adaptation
•
Apgar scoring system
Sign 0 Points 1 Point 2 Points
Skin colour* Extreme pallor Cyanotic extremities Totally pink

or central cyanosis
Muscle tone Absent Some flexion of extremities Active motion with complete
but hypotonic flexion of extremities
Respiration Absent Slow, irregular Normal (30-60 rpm)
Heartrate None ≤ 100 bpm >100 bpm
Responsiveness Absent Grimace Vigorous cry, good
*The skin colour changes quickly from blueish to pink within the first breaths taken by the newborn.
In babies with darker skin tones, colour should be assessed by observing palms of hands, soles of feet and
mucous membranes

1.2.2 First complete routine clinical examination
• Should be performed between the first 60 to 90 minutes of life
and after the baby has breastfed for the first time
• The exam should be done ideally with the mother holding
the baby. If not possible place the baby under a baby warmer
or in a heated room
• The physical exam can be combined with the administration
of TOT, vitamin K and cord care as per above flowchart
• Mother should be informed about the examination and for
what purpose it is carried out. Information on the findings of the
examination must be given immediately to the mother and birth partner
Clinical examination
Vital signs • Respiratory rate: normal range 30 to 60 breaths/minute, no gasping, no chest indrawing
• Heart rate: normal range 100 to 160 beats/minute
• Temperature: normal range ≥ 36 °C and < 37.5 °C
Weight • Weight the neonate naked on a calibrated scale. Normal weight in term newborns is 2.5 kg-4 kg
Skin • Pink, homogeneous, no lesions
Head • No haematomas

• Moulding or caput are normal findings that disappear within 2-3 days
• Fontanelles, eyes, ears, nose, palate, tongue, lips
Chest • Homogeneously rising with respiratory efforts, normal hear and breath sounds
Abdomen • Homogenous shape, normal size, umbilicus without hernias, cord well clamped
Extremities • Normal shape and size. Number of fingers and toes

• Moving symmetrically on both sides
Back • Intact spine and skin above spine
Genital organs and anus • External exam only without introducing any finger or probe
Responsiveness • Flexed posture, active tone, sucking and grasping reflex present, responds to stimulation

1.3 Routine newborn care: 90 minutes to 24
hours after birth
• Admission after a normal uncomplicated vaginal birth should
be at least for 24 hours to monitor mother and baby
• Rooming (mother and baby should be in the same room)
is always recommended to support breastfeeding on demand
and healthy bonding of mother and newborn
1.3.1 Routine monitoring

• A newborn with no abnormal signs on exam should be routinely monitored
every 6 hours for:
– Vital signs: temperature, RR, HR
– Urine and stool passage should occur within the first 24 hours of life
– Breastfeeding:
• Exclusive breastfeeding needs to be encouraged. No water or other
fluids should be administered to the newborn
• Breastfeeding should be on demand and with intervals of not more
than 3 hours
• Poor sucking tonus is one of the first signs of neonatal sepsis
• Assist mother in appropriate position and latch of the newborn
to avoid cracked nipples and pain

1.3.2 Assessment of infection risk
All asymptomatic neonates must be assessed for their risk of infection and
if at risk, administered prophylactic antibiotics for 48 hours. Neonates are
considered at risk in the following cases:
• Membranes ruptured > 18 hours before delivery. Exception: mother
with PROM > 12 hours and no fever during labour that received at least
2 doses of ampicillin IV every 4 hours and the last dose 4 hours before
delivery
• Mother had fever > 38 °C before delivery or during labour
• Amniotic fluid was foul-smelling or purulent
• In twin pregnancies: one twin has clinical signs of infection.
Give ampicillin and gentamicin IV or IM for at least 2 days and reassess;
continue treatment only if there are signs of sepsis (or a positive blood culture)
≤ 2000 g > 2000 g
Ampicillin IV or IM 50 mg/kg every 12 hours 50 mg/kg every 8 hours
Gentamycin IV or IM 3 mg/kg every 24 hours 5 mg/kg every 24 hours

1.3.3 Assessment of hypoglycaemia
Check blood glucose within one hour of birth in neonates with one of the
following risk factors:
• Birth weight < 2500 g or > 4000 g
• Maternal diabetes (gestational or pregestational)
• Mother treated with labetalol during labour or just before labour
• Difficult breastfeeding: difficulty with sucking or attaching to the breast
If blood glucose is normal: Monitor adequate breastfeeding (In demand,

≥ 2.5 mmol/l or ≥ 45 mg/dl at least every 3 hours).Check blood glucose
before each meal or every 2 hours until there
are 3 consecutive normal results
If blood glucose is See hypoglycaemia

< 2.5 mmol/l or < 45 mg/dl
1.3.4 Assess for any mother to child

transmissible diseases
Check HIV and syphilis status of mother and proceed accordingly
1.3.5 Vaccination
Administer first dosage of hepatitis B, BCG and polio vaccines (according
to national protocols)

1.3.6 On discharge
1.3.6.1 Full examination
Extremities • Both legs and arms should move equally and symmetrically
• Baby should open mouth and turn the head to search for nipple when the cheek is stroked
lightly
Skin • There may be a bluish area over the back with some peeling of the skin
Head • Certain moulding (elongated head, asymmetry) or caput succedaneum may persist
for 2-3 days after birth
Eyes • No discharge, redness or swelling

• Symmetrical
Ears • Symmetrical in position and above lower jaw line

• Accessory skin tags may be present and should be noted
Mouth • Lips, gums and palate intact and equal on both sides
• Observe breastfeeding to detect any problem in the latch. A short tongue tie maybe the
reason for painful breastfeeding or cracked nipples
Chest • Moves equally with respiration

• Breasts may be swollen at birth due to pregnancy hormones but will return to normal
during first weeks
Abdomen • Rounded and soft, no apparent distension neither masses

• Pushes out with each breath
• Cord well clamped, no bleeding or discharge. If the cord becomes loose as it dries,
put on gloves and re-clamp the cord
Back and spine • No openings on the skin

• No defects in the spine
Anus • Do not insert instruments or finger

• Inspect for patency – confirmed by passage of stool
Female external genitalia • A white vaginal discharge is normal

• A bloody discharge that starts on day 2 – 3 days until seven days is normal
Male external genitalia • Urethra opens at the end of penis

• Testes are felt in the scrotum
• No sign of infection or bleeding if circumcision has been done
Weight • Normal range is 2.5 kg to 4 kg

• Newborns might lose 5-10% of their birthweight in the first 24-72 hours but birthweight
is usually regained by day 14
1.3.6.2 Vitamin D
• Should be given ideally to all neonates on discharge and until 6 months of life
• Preterm or neonates living in contexts of high-risk vitamin D deficiency: 600 to
1200 IU once daily
• Term neonates: 400 to 800 IU once daily

1.3.6.3 Information
• Exclusive breastfeeding on demand
• Keep baby warm: facilitate skin to skin contact as much as possible, cover
baby’s head the first days, touch baby’s feet and if cold an extra layer of clothes
are needed
• Advise on how to bathe the baby for the first time or do it with the mother for
the first time
• Educate on danger signs
Danger signs for newborns to be recognised by the mother
• Breathing problems or fast breathing (>60 breaths per minute)

• Chest indrawing
• Feeding difficulties or refusal to feed
• Hypotony (not moving spontaneously)
• Feels cold
• Fever
• Red, swollen eyelids or pus from eyes
• Redness of skin, swelling, pus or foul smell from cord
• Fits or convulsions
• Yellowness of skin
• Persistent vomiting
• Bulging or depressed fontanelle

• Cord care:
– Keep cord stump loosely covered with clean clothes
– Fold diaper below the stump
– Do not put creams or local remedies on the stump
– Wash stump with clean water and soap while bathing the baby once daily (or
if visibly dirty) and dry it thoroughly with a clean cloth
– Seek care if the umbilicus is red or draining
• Give appointment for postnatal visits (mother and baby) at the following
intervals. Postnatal visits can also be done through home visits
– 48-72 hours: if caesarean section, this follow up can be done while admitted
– 7-14 days
– 6 weeks
1.4 Routine newborn care: from discharge

to 6 weeks postnatal period
In all postnatal visits perform:
• Complete clinical exam
• Vaccination according to schedule
• Ask mother about breastfeeding, baby’s stools, and urine
• Ask about any problems
• Support exclusive on demand breastfeeding. If possible, observe
breastfeeding
• Continue with vitamin D
• Repeat information on danger signs

2.0 N
ewborn Resuscitation
While most babies go through the transition from intra-uterine to

extra-uterine life with minimal assistance, about 10% of newborns
require assistance
Failure to provide this assistance immediately after birth could cause
birth asphyxia, with long term complications and even death. The term
“golden minute” highlights the steps that need to be taken in the first
60 seconds in the life of a baby and without delay: thermoregulation,
stimulation to breathe and assisted ventilation if necessary
In healthy babies, the golden minute is also vital to start skin-to-skin
contact and delayed cord clamping which has proven better breastfeeding
uptakes and less delayed neonatal complications
The below flowcharts summarise when and what steps must be taken
during a newborn resuscitation. Details on the technique of the specific
steps are provided afterwards
2.1 Equipment
The necessary equipment for immediate newborn care and resuscitation
needs to be prepared before the delivery for all cases
Necessary equipment for immediate newborn care and resuscitation
• Gloves
• Cloths and head cover for the newborn
• Clean sterile scissors
• Clamps or ties for the cord
• “Penguin” suction device. Deep suction with probes and suction machines are NOT
RECOMMENDED
• Bag-mask for ventilation: at least mask sizes 0 and 1 are required
(for small and term babies)
• Stethoscope
• Timer (clock, watch)

2.2 Neonatal resuscitation algorithm
During the first 30 seconds

• Deliver the baby on a dry cloth on mother’s abdomen
• Dry the baby vigorously
• Check the breathing while drying

GOLDEN MINUTE
YES NO
Monitor with mother BASIC RESUSCITATION

Routine care • Call for help and gently explain to mother what is happening
• Clamp/cut the cord using sterile scissors and gloves
• Transfer the baby to the newborn resuscitation area
• Position head/neck
• Only suction if the mouth/nose are blocked and only with the bulb syringe
• Start bag/mask ventilation with air for 30 seconds

YES
NO
Continue ventilations for 1 min

Check heartbeat
Heartbeat > 100 bpm Heartbeat 60-100 bpm Heartbeat < 60 bpm
• Check and ensure proper seal of mask and • Check and ensure proper seal of mask and
effective chest rise for effective ventilation effective chest rise for effective ventilation
• Continue ventilation and check respiration • Add O² 2L/min to bag
and heartbeat every 30 seconds • Start chest compressions: 3 compressions for
• Consider more advanced paediatric care every 1 ventilation (ratio 3:1)
by a paediatrician: IV access, adrenaline, • Reassess every 30 seconds
intubation
• Consider more advanced paediatric care by a
paediatrician: IV access, adrenaline, intubation
STOP resuscitation if:

• No heart rate after 10 minutes
• No spontaneous breathing after 20 minutes even with adequate heart rate

2.3 Basic resuscitation
2.3.1 Stimulate baby
Stimulate the baby by vigorously drying it, rubbing the soles of the feet
and the back.
Do not lift the baby by its feet nor slap the baby
2.3.2 Clear airway

• Neutral position: Place newborn on its back and the head into a neutral
position (not too flexed, neither too extended). It may help to place a towel
(2 cm thick) under the shoulders
• Suction: Only suction if there is visible and copious secretions. Use a
bulb syringe (penguin type) to suction only the mouth and not more than 2
cm deep and not for more than 5 seconds
Deeper suction may depress respiratory efforts in a newborn, it delays
the start of effective ventilation and sometimes even push secretions
Figure 1. Neutral position of head
deeper down the airway. Even in meconium stained newborn follow
the same advice
2.3.3 Perform bag-mask ventilation

• A correctly sized fitting mask is required. It should cover the mouth
and nose, and not go over the eyes or the edge of the chin
• Fit the mask with the non-dominant hand holding it between thumb,
index and middle finger
• With the dominant hand, squeeze the bag 30-60 breaths/minute
for 1 minute (1 inflation should take 2 seconds)
• Effective ventilation should make the chest rise (too much pressure
will cause a pneumothorax)

• If the chest is not rising:
– Check the mask and bag are well connected (should have been done
before delivery)
– Correct the position of the mask on the face, make sure you have the
appropriate size
– Correct the position of the baby’s head. In very floppy babies you may
need to slightly lift the jawbone of the baby or have an assistant do it
• Do not stop ventilations to check for breathing or heartbeat; an assistant
should do this
• O² can be connected to the bag by an assistant after 2 minutes of
resuscitation
CORRECT WRONG WRONG WRONG
Correct size and correct

Mask held too low Mask too small Mask too big
position of mask
Figure 2. Fitting mask over face (WHO)

Lift the chin with the third finger 2.3.4 Chest compressions
of the hand holding the mask
• Need for performing chest compressions is extremely rare as once
Do not hyperextend the neck
correct ventilation has occurred an increase in heartrate usually follows
Make sure the ventilation is effective (chest rising, colour of baby
is turning pink) before starting chest compressions
• If the baby’s heartbeat is below 60 bpm despite effective ventilation
for 30-60 seconds, have an assistant start chest compression with
ventilations at a ratio of 3:1 (approximately 90 compressions and
30 breaths per minute). Rescuer 1 coordinates ventilations with
compressions
• Do not stop ventilations to do chest compressions
Figure 3. Adequate ventilation with bag

– If you are resuscitating the neonate alone continue only with effective
and mask (WHO)
ventilations until help arrives or stop after 20 minutes
– If no providers skilled in chest compressions are present it is better
The most effective manoeuvre for to continue effective ventilations than to start ineffective chest
neonatal resuscitation is effective compressions
ventilation
• Technique:
– Both hands encircling chest, thumbs side by side or overlapping
on lower third of sternum: trace an imaginary line between both
mammary glands and place the thumbs 1 cm below. Thumbs remain on
sternum between compressions
– Compress the chest to 1/3 of its depth
– Or using tips of two fingers: middle finger and index or ring finger are
positioned perpendicular to the chest on the lower half of sternum.
Tips of fingers remain on sternum between compressions
Figure 4. Chest compressions with both

hands around baby’s chest and both
thumbs on sternum

2.3.5 Stop resuscitation efforts
• Stop resuscitation if:
– No heart rate after 10 minutes
– No spontaneous breathing after 20 minutes even with adequate
heart rate
• Inform mother and prepare birth certificate
2.4 Post-resuscitation care

Any neonate with an Apgar < 5 at 1 minute and < 7 at 5 minutes requires
transfer with the mother to a neonatal care unit for further observation and
management
For other neonates recovering from a resuscitation:
• Check vital signs and danger signs every 15 minutes for the first 2 hours
and every 2 hours for at least the next 24 hours
• Check blood glucose
• Perform a retrospective Apgar score
• As much as possible keep the neonate skin-to-skin with its mother
as it supports thermo and breathing regulation
• Start breastfeeding as soon as possible
• Evaluate the need for antibiotics (see above)
• Ensure routine care (see above)

3.0 C
are of Sick Newborns
3.1 General danger signs

Danger signs must be assessed for every newborn immediately after birth,
during admission and at each postnatal consultation
Presence of any of the below danger signs requires immediate
management. Depending on the severity of the situation and the level
of neonatal care available at the facility, the neonate (and mother) will
need to be referred for higher level care
Table 1. Neonatal danger signs
Temperature ≥ 37.5 ºC or ≤ 36.5 ºC
Skin • Blue colouring (cyanosis)

• Extreme pallor
• Extensive jaundice (yellow colouring) that includes palms
and soles or starts before 24 hours (see below)
• Umbilicus is red and/or having a bloody or pus discharge
• Pustules or generalised rash
Respiration • No breathing
• Respiration rate < 30/min or > 60/min
• Severe chest indrawing (retraction of area below rib cage)
• Grunting (short and low sounds with throat)
Heart • Tachycardia: heart rate > 180 bpm

• Capillary refill time > 2 seconds
Neurological • Bulging fontanelle

signs • Hypotonia: movement only when stimulated or no movement at all
• Drowsiness or unconsciousness
• Unable to feed
• Convulsions: sometimes neonatal seizures are subtle and
present as repetitive abnormal movements such as swimming
movement or eyelid blinking or deviation of eyes
Blood • Blood glucose < 35 mg/dl on one occasion

glucose or <45 mg/dl on more than 2 occasions
Others • Abdominal distension

• Swollen painful joints

3.2 Neonatal infection
All neonates without danger signs must be assessed for their risk of
infection and treated with antibiotics for 48 hours in case of risk factors
(see above).
The presence of any of the above danger sings may indicate a neonatal
infection in addition to specific signs that may appear in form of pneumonia,
meningitis (bulging fontanelle, lethargy, irritable with high-pitched cry,
convulsions), skin pustules, umbilical redness and pus discharge, swollen
and red joints, etc.
3.2.1 General management

• Refer to neonatal care unit
• General management:
– Put on nasal prongs with a flow rate of 0.5–1L O² per minute (max 2L/
min)
– Check glucose and encourage feeding. If feeding not possible start IV
fluids
– Keep warm
• Administer antibiotics (see dosages in table below):
– Use ampicillin IV and gentamicin IM
– Second line (do not use in suspected meningitis): procaine
benzylpenicillin IM and gentamicin IV
– In case of skin infection as primary source: replace ampicillin
with cloxacillin IV
– Treat for 7-10 days, stopping gentamicin after 5 days

Table 2. Antibiotics for neonatal infection
≤ 2000 g > 2000 g

Ampicillin IV (or IM) • First week of life: • 50 mg/kg every 8 hours
50 mg/kg every 12 hours • If meningitis: 100 mg/kg
• If meningitis: 100 mg/kg every 8 hours for 21 days
every 12 hours for 21 days
Gentamycin IM • 3 mg/kg every 24 hours • 5 mg/kg every 24 hours

(IV also possible)
Procaine • 50 000 IU/kg every 24 hours

benzylpenicillin IM (not indicated when meningitis is suspected)
Cloxacillin IV • 25 mg/kg every 12 hours • 25 mg/kg every 8 hours

(infusion)
3.2.2 Conjunctivitis
• Mild conjunctivitis: sticky eyes, but only mildly swollen, without pus
discharge
Teach mother to:
– Wash hands before and after cleaning the eyes
– Wash the eyes 4 times a day from inner to outside angle
with clean, boiled water that has cooled or with breastmilk
– Apply tetracycline eye ointment 1% after each cleaning for
a total of 5 days
– Come back if no improvement after 2 days of treatment or recurrent
conjunctivitis after finalising treatment

• Severe conjunctivitis: red and swollen eyes with pus discharge
– Most commonly due to a mother to baby transmission during delivery
(Neisseria gonorrhoea, Chlamydia trachomatis)
– Admit baby
– Administer ceftriaxone 50 mg/kg IM stat dose
– Clean as per above and administer tetracycline eye ointment 1%,
4 times daily for 5 days
– Treat mother for STI
3.3 Jaundice
Jaundice is the yellow colouring of the neonate’s skin and eye sclera
due to increased levels of bilirubin in the blood. Depending on when the
jaundice starts and how it extends, it can potentially be severe and lead
to an encephalopathy with severe sequelae (kernicterus)
3.3.1 Physiological jaundice

• Starts after 48 hours of birth and usually disappears within 2 weeks
• Yellow colouring of eyes and skin but without affecting palms and soles
Neonates with physiological jaundice can be discharged with the following
advice:
✔ Put baby under indirect sun light
✔ Continue breastfeeding (8-12 times per day)
✔ Return if jaundice persists after 2 weeks of birth, or stools become
pale and/or dark urine

3.3.2 Pathological jaundice
• Starts in the first 24 hours of life
• Lasts more than 14 days in term or more than 21 days in preterm infants
• Accompanied by fever
• Presents first on face and extends to feet and hands
• Caused by blood disorders (group or Rh incompatibility, haemolytic
anaemia) or serious infections (including congenital syphilis), liver
diseases, etc.
Referral criteria to neonatal unit (higher level) include:
✔ Jaundice that starts in the first 24 hours of life
✔ Jaundice in preterm neonates < 35 weeks
✔ Extensive jaundice that affects palms and soles at any time
✔ Any other danger sign present even if jaundice seems physiological
Further investigation will be carried out in the neonatal unit (e.g. full blood
count, bilirubin, syphilis testing, etc) and management with phototherapy
may be initiated

3.4 Convulsions
• Convulsions can be caused by birth asphyxia, hypoglycaemia,
hypocalcaemia, birth injuries and neurological problems as well as
meningitis and other neonatal infections
• Sometimes neonatal seizures are not obvious but present rather
as repetitive abnormal movements such as a swimming movement,
a repetitive eyelid blinking or deviation of eyes
Management:
If the seizure lasts more than 3 minutes proceed as follows:
• Ensure open airway
• Check blood glucose and treat accordingly. If blood glucose cannot
be measured treat as if the neonate was hypoglycaemic
• Rule out hypocalcaemia: check if the mother was under labetalol
treatment. Check calcium if laboratory available
• Start treatment for infection if there are any risk factors or the neonate
present any other danger signs besides the convulsions
• Give a loading dose of phenobarbital 20 mg/kg IV over 15 minutes
or single IM injection and arrange for transfer to neonatal care unit
• A second dose of 10 mg/kg slow IV or IM can be given if the convulsions
do not stop within 30 minutes of the first dose

3.5 Cyanosis or difficult breathing
Cyanosis or difficult breathing can present as RR < 30 or > 60, grunting or
a indrawing of the chest in the neonate
Management:
• Check O² saturation
• If O² sat < 90%: administer O² with nasal prongs at 0.5-1L per minute
(maximum 2L per minute). The target is to keep O² saturations
between 90-95%
• If there are obvious secretions in mouth or nose and the newborn is too
weak to expel them, clear airway with suction
• Keep baby warm
• Transfer to neonatal unit
• If not breathing or gasping: proceed to neonatal resuscitation
3.6 Lethargy
Neonate is drowsy, has a low muscular tone, or moves only after stimulation
or not at all. Lethargy is a sign of severe illness in the newborn
Management:
Ensure immediate transfer and in the meantime:
• Keep baby warm
• Open airway by placing the baby on its back and administer O² by nasal
prongs 0.5-1L/minute
• Start antibiotics for infection and give vitamin K if not provided before
• If not breathing or baby is gasping: start resuscitation

3.7 Hypothermia and hyperthermia
3.7.1 Hypothermia
Hypothermia is often a sign of infection
• Remove any wet clothes on the baby
• Wrap the baby in soft, dry clothes, making sure the head is covered
• If possible: skin-to-skin contact with mother covered with blanket
• If skin-to-skin is not possible, use a radiant warmer or incubator
• Check breathing and blood glucose and treat accordingly
• Encourage breastfeeding and if not possible, start alternative feeding
method with cup or nasogastric (NG) tube expressing breastmilk (see
Section 4.0 for advice on breastmilk amounts for low birth weight and
preterm babies)
• Start antibiotics for infection
• Measure temperature every hour: if it increases by ≥ 0.5 ºC each hour, the
measures have been successful. When it increases to normal continue
measuring every 4 hours for the next 24 hours.
3.7.2 Hyperthermia
Hyperthermia is often a sign of infection
• Do not administer paracetamol or other antipyretics
• Undress the baby and control the external conditions (in hot settings
place a fan at distance to cool down the neonate) to lower the body
temperature
• Administer antibiotics

3.8 Hypoglycaemia
Common condition in neonates that often presents without symptoms
Hypoglycaemia in neonates need to be suspected and checked in all the
below cases:
• Neonates at risk of hypoglycaemia:
– Mother treated with labetalol
– Baby > 4000 g or < 2500 g
– Mother with gestational diabetes or diabetes in pregnancy
– Difficulty in breastfeeding
• Neonates with following signs or symptoms:
– Hypothermia
– Convulsions
– Difficult breathing or cyanosis
– Lethargy and hypotonia
– Irritable and trembling
3.8.1 Diagnosis
Capillary blood glucose (CBG) taken from the side of the heel of the baby
and tested with calibrated glucometer

3.8.2 Management
Figure 5. Management algorithm of neonatal hypoglycaemia
CBG 35-44 mg/dl (2-2.4 mmol/L) CBG < 35 mg/dl (< 2.4 mmol/L)
AND asymptomatic OR symptomatic neonate
OR recurrent hypoglycaemia
• Feed neonate: breastfeeding

or express breastmilk and administer 10% glucose 5 ml/kg PO or via NG tube
with cup or syringe over 5-10 min or 2 ml/kg of 10% glucose
• If no milk available: administer IV over 2-3 min
10% glucose 5 ml/kg oral over 5-10 min
(with cup or syringe)
Check CBG after 30 min
Check CBG after 30 min
CBG ≥ 45 CBG <45 mg/dl

(2.5 mmol/L) OR still
Follow same symptomatic
CBG ≥ 45 CBG <45 algorithm as on left
(2.5 mmol/L) (2.5 mmol/L)
Give second dose of glucose 10%

Regular feeding every 2-3 hours and refer to neonatal unit
Check CBG before each feeding. Stop
checking if 3 consecutive normal results
If the referral/transfer is not immediate:

• Start infusion with 10% glucose
(80 ml/kg/24 h) and monitor CBG
every 30 min
• Start antibiotics
• Monitor breathing and vital signs
(temperature, HR)

4.0 C
are of Preterm and Low
Birth Weight Newborns
A low birth weight (LBW) newborn can be either premature (< 37 weeks GA)
or the result of an intrauterine growth restriction (or both factors together)
4.1 Risks/complications
LBW newborns are at risk of:
• Hypothermia
• Feeding problems
• Respiratory distress
• Infection
• Jaundice
4.2 Management
• Newborns born weighing 2000-2500 g (between 35-36 weeks GA):
usually are strong enough to breastfeed and maintain body temperature.
They should always be kept warm (skin-to-skin, kangaroo care)
and be monitored closely for any danger signs. Mother must be supported
and encouraged for exclusive and frequent breastfeeding (10-12 times
per day)
• Newborns born weighing 1500-2000 g: if they present without any
danger signs, they can be taken care in a regular neonatal unit with
constant kangaroo care, supplemental feeding, and close monitoring
• Newborns < 1500 g or newborns > 1500 g but with danger signs:
will need care in a high-level specialised neonatal unit due to their
high risk of complications
All LBW are at an increased risk of acquiring an infection. Rigorous
infection prevention control (IPC) measures need to be in place and mother
must be counselled and educated on hand washing each time before and
after handling the baby
Newborns > 1500 g without danger signs will all need the following general
care:

4.2.1 Preventing hypothermia
• Do not bathe in the first 24 hours to avoid a drop in baby’s body temperature
• Provide kangaroo mother care (KMC) starting soon after birth and as
much as possible: infant will only be dressed in nappy, socks and hat and
placed skin-to-skin on the mother’s chest. Mother ties infant with a cloth
and dresses herself in comfortable clothes
• KMC is not only a proven method to avoid and treat hypothermia but also
reduces episodes of apnoea and bradycardia and supports breastmilk
production
• Monitor temperature every 4 hours and proceed as per hypothermia care
• If mother is unable to provide KMC, the father or another family member
should be encouraged to do so. If not possible an incubator can be used
with appropriate IPC measures
Figure 6. Kangaroo mother care (WHO 2014)

4.2.2 Feeding
• Newborns that can suckle and breastfeed should have their weight
monitored daily as well as with blood sugar as per hypoglycaemia chapter
(CBG before meals or every 2 hours and stop monitoring if 3 normal
consecutive results)
• Newborns that are not breastfeeding well will need support.
Expressed breastmilk fed with cup or spoon is the first preferred
alternative see Figure 7). Formula should be given only when
there is no other option
– Start with 60 ml/kg/day of milk, distributed into 10-12 feeds,
and increase by 20 ml/kg/day every day
– Newborns not able to feed with spoon or cup will need feeding
bolus through NG tube and thus referral for higher level care
• Newborns < 1500 g are at high risk of developing a necrotizing
enterocolitis when orally fed. Therefore, they need referral to higher level
care for appropriate management. Until transfer is arranged, administer
IV fluids with glucose 10% solution at 60 ml/kg/day
4.2.3 Monitoring
All LBW newborns require monitoring for:
• Daily weight
• Temperature every 4 hours during admission
• Glucose monitoring as per hypoglycaemia algorithm
Figure 7. Expressed breastmilk

and cup feeding (WHO 2014)

4.2.4 Discharge
Infants with LBW can be discharged if:
• No danger sings
• Breastfeeding without problems
• Gaining weight
• Temperature is well maintained
• Mother feels confident enough to care for the baby and has been
educated on recognition of danger signs, IPC and breastfeeding

5.0 References
• World Health Organization, Regional Office for the Western Pacific. Early
essential newborn care: clinical practice pocket guide: first embrace.
Geneva, Switzerland: World Health Organization, Regional Office for the
Western Pacific; 2014.
• World Health Organization, editor. Pocket book of hospital care for
children: guidelines for the management of common childhood illnesses.
Second edition, 2013 edition. Geneva, Switzerland: World Health
Organization; 2013. 412 p.
• World Health Organization. WHO recommendations on postnatal
care of the mother and newborn.2013.https://apps.who.int/iris/bitstream/
handle/10665/97603/9789241506649_eng.pdf?sequence=1
• World Health Organization. Managing Complications in Pregnancy and
Childbirth, 2017. https://apps.who.int/iris/bitstream/hand
le/10665/255760/9789241565493-eng.
pdf;jsessionid=28797ACA5A26CA683EAD63F667EA
7107?sequence=1
• Essential obstetric and newborn care. Geneva: Médecins Sans
Frontières; 2019.
• PATH. A toolkit for procuring quality-assured basic neonatal resuscitation
commodities. Version 2 [Internet]. Save the Children; 2016 [cited 2020 Oct
15]. Available from: https://www.path.org/
resources/a-toolkit-for-procuring-quality-assured-basic-neonatal-
resuscitation-commodities/
• Helping Babies Survive: Helping Babies Breathe [Internet]. American
Academy of Pediatrics. 2019 [cited 3 October 2020]. Available from: https://
www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/helping-
babies-survive/Pages/Helping-Babies-Breathe.aspx.

MSI Reproductive Choices T +44 (0)20 7636 6200 Registered Charity No.
1 Conway Street F +44 (0)20 7034 2369 265543
Fitzroy Square
London W1T 6LP info@msichoices.org Company No.
United Kingdom www.msichoices.org 1102208
© MSI Reproductive Choices 2021

MSI Guidelines For Obstetric Care v2.0

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MSI Guidelines for

Module 1: Antenatal Care

1.0 Introduction 1.2

Module 2: Common Pathologies in Pregnancy

1.0 Iron Deficiency Anaemia in Pregnancy 2.2

Module 3: Intrapartum Care for Normal Labour and Vaginal Delivery

1.0 Stage of Labour 3.2

Module 4: Obstetric Complications

1.0 Pre-Labour Rupture of Membranes 4.2

© MSI Reproductive Choices 2021

Module 5: Obstetric Procedures

1.0 Manual Removal of Placenta 5.3

Module 6: Postnatal Care and Postnatal Complications

1.0 The Postnatal Period 6.2

Module 7: Newborn Care

1.0 Essential Newborn Care 7.2

2.0 Antenatal Contacts 1.3

3.0 Overview of Preventive Measures in ANC 1.10

4.0 Client Education and Counselling 1.14

5.0 Documentation 1.18

6.0 References 1.19

Appendix 1: Birth plan template 1.20

V1.0 MSI Reproductive Choices Guidelines for Antenatal care 1.1

This module focuses on basic, non-specialised antenatal care. According

The provision of information and the appropriate support to the

V1.0 MSI Reproductive Choices Guidelines for Antenatal care 1.2

2.1. Schedule of antenatal contacts

Table 1: Antenatal contact schedule

V1.0 MSI Reproductive Choices Guidelines for Antenatal care 1.3

V1.0 MSI Reproductive Choices Guidelines for Antenatal care 1.4

V1.0 MSI Reproductive Choices Guidelines for Antenatal care 1.5

V1.0 MSI Reproductive Choices Guidelines for Antenatal care 1.6

V1.0 MSI Reproductive Choices Guidelines for Antenatal care 1.7

2.3.1. Clients history

2.3.2. Physical exam

V1.0 MSI Reproductive Choices Guidelines for Antenatal care 1.8

V1.0 MSI Reproductive Choices Guidelines for Antenatal care 1.9

Table 2: Preventive measures in ANC

V1.0 MSI Reproductive Choices Guidelines for Antenatal care 1.10

V1.0 MSI Reproductive Choices Guidelines for Antenatal care

V1.0 MSI Reproductive Choices Guidelines for Antenatal care

Weight and BP All visits x x x x x x x x

Maternal and foetal assessment

V1.0 MSI Reproductive Choices Guidelines for Antenatal care

Client education and counselling is as important as any medical interventions.

4.1. General health advice

V1.0 MSI Reproductive Choices Guidelines for Antenatal care 1.14

Table 3: Birth preparation

V1.0 MSI Reproductive Choices Guidelines for Antenatal care 1.15

V1.0 MSI Reproductive Choices Guidelines for Antenatal care 1.16

Management in a CEmONC (absolute indications)

4.5. Individual and group sessions

V1.0 MSI Reproductive Choices Guidelines for Antenatal care 1.17

V1.0 MSI Reproductive Choices Guidelines for Antenatal care 1.18

• WHO recommendations on antenatal care for a positive pregnancy

V1.0 MSI Reproductive Choices Guidelines for Antenatal care 1.19

Where to give birth

I would like to give birth at home

I would like to give birth in a midwifery unit (BEmONC)

I would like to give birth in a maternity team unit in hospital (CEmONC)

I am not sure yet where I would like to give birth

My comments on where I would like to give birth and why:

I have identified and arranged a 24/7 transport plan

• WHO recommendations on antenatal care for a positive pregnancy