ECLAMPSIA

Pregnancy with Convulsion and BP ≥ 140/90 mm Hg

Immediate Management
Keep women in bed with padded Position her on left side, Oropharyngeal
1 rails on sides, preferably near
nursing station 2 airway to be kept patent, Oronasal suction
to remove secretions and put airway 3 Ensure preparedness to manage
maternal and foetal complications

Start Oxygen by mask at 6-8 l/min, Start IV fluids-RL/ NS at 75 ml/hr

Acute hypertensive crisis Anti Convulsants • Deliver the baby irrespective of

gestational age after stabilization and
SBP≥ 160 mm Hg or Drug of Choice - Magnesium Sulfate (MgSO4) reviewing investigations
• Convulsion-delivery interval should not
DBP≥110 mm Hg • *Loading Dose - Total 14 gm of MgSO4 be more than 12 hours. But can wait
Aim for SBP between 130-150 mm 1) 4 gm of 20%, slow IV in 5 – 10 mins 2) 10 gm of 50%, deep IM (5 gm in each buttock) for vaginal delivery if patient goes in
Hg DBP 80-100 mm Hg. active labor within this time
5gm of 50% (10ml) 5gm of 50% (10ml)
8 ml of 50% MgSO4
• Inj Labetalol 20 mg IV bolus slowly
over 1-2 min, if BP not controlled,
12ml
= diluted with 12 ml
NS
Normal Saline / Distilled
+ + +
50%

50%

50%

50%
2ml

2ml

2ml

2ml

repeat 40 mg after 10 minutes, Water (Total 20 ml)

50%

50%

50%

50%

50%

50%

50%

50%

50%

50%
2ml

2ml

2ml

2ml

2ml

1ml

2ml

2ml

2ml

2ml

2ml

1ml
2%

2%
repeat 80 mg every 10 minutes if 8ml MgSO4 Favourable
MgSO4 MgSO4
Unfavourable
BP not controlled (max 300 mg) with Xylocaine Xylocaine Cervix
Cervix
cardiac monitoring Left Buttock Right Buttock Bishop score 6 or
Bishop score 5 or
more- Cervix soft,
OR less- Cervix firm,
If recurrent fits after 15 – 30 mins of loading dose – short, partially
long, closed
• Inj Hydralazine 5 mg I/V slowly repeat 2 gm 20% slow IV in 2 minutes. dilated
over 1-2 min, if BP not controlled,
repeat 5-10 mg over 2 min after 4 ml of 50% MgSO4
20 min. If BP not controlled again
repeat 10 mg over 2 min (max 20
6ml
NS = diluted in 6ml Normal
Saline (Total 10ml) • Induction
with Artificial • Ripening with
50%

50%
2ml

2ml

mg). If no response switch to other Dinoprostone

antihypertensive drug Rupture of
Membranes gel/Misoprostol
*Preparation of IV loading dose with 25% MgSO4; 16ml of 25% MgSO4 diluted with 4ml Normal Saline/Distilled water (Total 20 ml)
OR and Oxytocin tablet/indwelling
• Maintenance Dose — 5 gm IM (50%) • Monitor • 2nd stage to catheter and
• Tab Nifedipine orally 10 mg stat, assess after 6
repeat 10-20 mg after 20 min, if BP Presence of Respiratory Urine Output be cut short
Deep IM, hours
by Forceps/
not controlled repeat 10-20 mg after = Alternate buttocks, Patellar Jerks Rate (RR)>16/min ≥30ml/hr in last
20 min (max 30 mg). {Give through + after monitoring,
every 4 hourly
4 hours Ventouse
Ryle’s tube if unconscious patient}. Continue maintenance dose till 24 hours after
50%

50%

50%

50%

50%
2ml

2ml

2ml

2ml

2ml

1ml
2%

If no response switch to other last fit/delivery, whichever is later

antihypertensive drug
• Keep record of BP as sometimes
there is sudden hypotension
• Continue B.P monitoring every
15 minutes for 2 hours after
stabilization then every 30 min for 1
hour. Then every hour, if in labor or
4 hours, if not in labor
10ml MgSO4 Xylocaine
If Patellar jerk absent or urine output <30 ml/hr
withhold MgSO4 and monitor hourly- restart
maintenance dose when criteria is fulfilled
Manage patient in Obstetric HDU. Active management of third
stage of labour is a must. Use of Methergine is contraindicated.
If platelet count is less than 30,000 (thrombocytopenia),
I/M regime is contraindicated. Use I.V regimen of Zuspan:
If RR < 16/min, withhold MgSO4, give
Magnesium sulphate 4g is given as IV loading dose in the
antidote– Calcium Gluconate 1 gm IV 10 ml beginning. This is followed by intravenous infusion of
of 10% solution in 10 minutes Magnesium sulphate at the rate of 1g/hour till 24 hours have
elapsed after the last seizure or after delivery,
whichever is later.
Supportive management:
Catheterize bladder. Monitor fluids input and output. Maintain airway,
regular suction. Monitor vital signs: pulse, BP, temperature, respiration.

Indication for
• If fits not controlled/status eclampticus • Foetal distress • Deteriorating maternal condition • Failed Induction • Any other obstetric indication Version 2022
C-Section:
 Management of Post Partum Hemorrhage (PPH)
Blood loss>500ml after vaginal child birth/>1000ml after C-section/or any loss
which deteriorates maternal condition

Patient received in Obstetric Triage of Emergency Room

Initial Assessment:
• A quick history with simultaneous assessment and initial management
• Ascertain the cause
• Continue with the steps of facility-based management (enumerated below)
Facility based management
• Call for help (mobilize all available personnel)
• Assess Airway Breathing and Circulation (ABC), check vitals
• Secure 2 wide bore IV lines (16/18 G)
• Collect blood for investigation: blood group and cross match, complete blood
count, blood coagulation profile-bedside clotting and clot retraction time
• Start IV fluids (0.9% Normal Saline/Ringers Lactate)
• Arrange and transfuse blood, when indicated as soon as possible
• Give inj oxytocin 10 IU IM (if not given after delivery)
• 20 IU of oxytocin in 1000ml of RL/NS or 10 IU of oxytocin in 500ml of RL/NS @
40-60 drops/mt
• Tranexemic acid 1gm in 10ml NS IV over 10 mins (100 mg/min); repeat another
dose after 30 min of first dose if required
Monitor
• Pulse rate, blood pressure, respiratory rate, temperature and bleeding per vaginum
• Catheterize and monitor urine output until the woman is stable (normal output
>30 ml/hr)

Check if placenta is expelled or not

Placenta is not expelled (Retained placenta) Placenta is expelled
• Continue oxytocin drip (Total oxytocin not to exceed 100 IU in 24 hrs) • Examine placenta and membranes for completeness
• If uterus is contracted, attempt controlled cord traction • Palpate the uterus per abdomen for the consistency. Rule out inversion of
• Give IV antibiotic or as per Protocol uterus
• Do manual removal of placenta under anaesthesia if required • Conduct uterine massage and continue oxytocin drip (Total oxytocin not
to exceed 100 IU in 24 hrs)

Uterus contracted/relaxed

Uterus well contracted, examine for Genital Trauma (Traumatic PPH)

• Look for cervical/ vaginal/ perineal tear - repair it Uterus is not well contracted/ soft and traumatic causes
• Continue Oxytocin drip excluded (Atonic PPH)
• If scar dehiscence or uterine rupture is suspected than shift to OT for laparotomy Continue uterine massage and oxytocin drip (total oxytocin
not to exceed 100 IU in 24 hrs)
• If uterus is still relaxed and bleeding uncontrolled
– Tablet Misoprostol (PGE1) 800 microgram sublingual/per
rectal
• If uterus is still relaxed and bleeding uncontrolled
Bleeding is uncontrolled – Inj Carboprost (PGF2 alfa) 0.25mg IM (contraindicated
• Arrange for blood transfusion in asthma)/ inj. Methyl ergometrine 0.2 mg IM/IV slowly
• Apply non-surgical compression: (contraindicated in hypertension, severe anemia, heart
disease)
- Bimanual uterine compression
- Uterine balloon tamponade (Condom over Foley’s catheter)
- External aortic compression
If no response
Check bleeding
• Shift to OT for surgical compression
• May consider Uterine Artery Embolization (UAE) in select cases such as with coagulopathy if
facilities available
If no response
• Systemic devascularization: uterine artery, ovarian artery, internal iliac artery ligation Bleeding is controlled
If no response • Repeat uterine massage every 15 min for first 2 hours
• Hysterectomy total or subtotal (timely hysterectomy) • Check vitals and bleeding per vaginum every 15 mins for 1st
Refer to higher center (with nearest distance) if above facilities are not available: one hour followed by every 1 hr for next 4 hours and then
every 6 hourly for next 24 hr
Continue oxygen with oxytocin drip and pressure to arrest bleeding by balloon tamponade/vaginal
packing/or external aortic compression during transfer • Continue Oxytocin infusion (Total Oxytocin dose not to
exceed 100 IU in 24 hrs)
• Closely monitor vitals and bleeding during transport
Follow up
• If available, consider use of well-equipped ambulance services with trained staff for emergency
interventions/resuscitation during transport • Checkup and treat for anemia after bleeding is stopped for
24 hours

Maintenance Dose of Uterotonics
Whenever needed:
• Inj Ergometrine can be repeated every 15 min. {0.2mg IM} (Max 5 doses = 1mg)
• Inj Carboprost can be repeated every 15 min. {0.25mg IM} (Max 8 doses = 2mg)
Map government and private centers/hospitals providing surgical management of
PPH for prompt referral and treatment to the nearest available center to avoid delay
in reaching the facility – The list and contact details of nearest centers should be
displayed for prompt reference
Follow complete referral protocol: Prior communication to referral facility is a must with
complete details of woman, management provided, confirm availability of space and
requisite staff, etc.

Version 2022
 OBSTETRIC TRIAGE PATHWAY
EMERGENCY
RED-IMMEDIATE
Seen by doctor immediately. Shifted to
labor/delivery room immediately or to
HDU/ICU after stabilization.
• Life–threatening conditions
• Vitals: (Mother)
– HR >130/min or < 60/min
– RR > 30/min or < 16/min
– Systolic BP ≥ 160 mm Hg or ≤
80/mm Hg
– SpO2 < 92%
– Fetal Bradycardia < 110/min
– Fetal Tachycardia >160/min
– Temperature < 95®F/35®C or
>102.0®F/39®C
• Women is unresponsive or altered
in mental status
• Detected high risk pregnancy during
ANC check up
– Cardiac problem
– Respiratory distress
– Eclampsia/any fits
– Bleeding per vaginum
• Frequent contractions with urge to
push
• No/decreased fetal movements/fetal
distress
• Cord/hand prolapse (protruding from
vagina)
• Signs of uterine rupture
• High grade fever
1. Greet the patient, ask her name, obstetric or non-
obstetric complaint.
2. Triage protocol– coded red, yellow or green.
3. Initial assessment and coding is entered on
Standard clinical triage assessment (initial assessment)
• Short history
• Vitals (HR, BP, SpO2, RR, Temperature)
• Pain score
• Abdominal palpation, foetal heart rate
• Level of alertness (mental status)
URGENT YELLOW EXPECTANT GREEN
Should be informed of the delay and
Should be seen within 30 min, and
the possible time of a checkup. In
have a check by triage nurse or doctor
case of a delay should be monitored at
every 15 min.
30 min intervals.
• All women in labour with frequent • Nausea/vomiting/diarrhoea
contractions (>3 contractions in 10 • Urinary complaints
mins) • Stable gestational hypertension
• Multipara in active labour • Wound infection/Check-Up
• Abdominal pain • Upper respiratory infection
• Pre-eclampsia • Vaginal discharge
• Preterm labour or preterm rupture • Skin suture removal
of membranes • Injections, lab draws
• Trauma or accident • Booking for antenatal care
• Psychiatric disorders • Review of reports
• High grade fever
THE STEPS IN TRIAGE ARE:
assessment form after checking vitals.
4. Unconscious patient is always coded red, with
code blue activation, resuscitation and shift to ICU.
5. Do not shift an unstable patient without stabilization.
Version 2022
 PARTOGRAPH

Name: W/o: Age: GPLA:

Date and Time of Admission: Date and Time of ROM (Rupture of Membranes):

200
190
180
Foetal heart rate

170
160
150
140
130
120
110
100
90
80

Amniotic fluid
Moulding
10
9
8
Cervix (cm) 7 Alert
ion
[Plot x] 6 Act
Hours

5
4
Descent 3
of head 2
[Plot o] 1
0
Hours 1 2 3 4 5 6 7 8 9 10 11 12

Time

5
Contractions
per 10 mins

<20 Sec
4

20 - 40 Sec 3
2
>40 Sec 1

drops/min

IV Fluids and
drugs given
180
170
160
150
Pulse 140
[Plot ] 130
120
110
100
BP 90
[Plot ] 80
70
60

Temp ºC/ºF

Protein
Urine
{ Acetone
Volume

Initiate plotting on alert line Refer to FRU When
• FHR is <120 beats/min or >
• FHR, status of membranes and amniotic fluid, uterine contractions 160 beats/min
and pulse are recorded every half an hour • Meconium and/or blood
• Cervical dilatation, BP and temperature are recorded every 4 hours stained amniotic fluid
• When cervical dilatation plotting
crosses the alert line
• Contractions not increasing in
duration, intensity and frequency
e.g. 2 or less. Contractions lasting
for <20 sec in 10 min

Normal Vaginal delivery Assisted delivery Shifted for C-section

Date and Time of delivery____________________ Baby weight___________(In gms) Apgar score____________ Sex of baby M F
Robson's group______________
Version 2022
 PRE-ECLAMPSIA
SBP≥140mm Hg or Proteinuria ≥0.3 g/24-hour
Period of DBP≥90 mm Hg or both urine specimen or protein/
gestation>20 on 2 occasions, 4 hours creatinine ratio ≥0.3 (mg/mg)
weeks apart in a previously or (30 mg/mmol) in a random
normotensive patient urine specimen or dipstick ≥2+

Pre Eclampsia without severe features

• SBP≥140mm Hg or DBP≥90 mm Hg or both
• Proteinuria ≥0.3 g/24-hour urine specimen or protein/creatinine ratio ≥0.3 (mg/mg) or (30 mg/mmol) in a random urine
specimen or dipstick ≥2+

• Hospitalize, reassure, advice rest

• Start anti-hypertensive agent when SBP≥ 150mm Hg and or diastolic ≥ 100mm Hg
• Tab Labetalol 100 mg 8–12 hourly (max 2.4 gm/day)
OR
• Tab Alpha Methyldopa 250-500 mg / 6-8 hourly (max 2gm/day) (as per availability)
• Investigate — CBC with peripheral smear and platelet count, LFT, KFT and fundus exam
• BP and urine output monitoring

Frequency of Investigation
• Continue hospitalization
• Regular foetal+maternal surveillance Parameter Frequency
Hb Weekly

Platelets Weekly

LFT Weekly

KFT Weekly
• Maintain DBP If disease is
Fundus Once
90-100 mm Hg severe, manage
• No foetal as severe NST/BPP After 32 Weeks
compromise pre-eclampsia
Doppler Study 3 – 4 Weeks

BP Monitoring 4 times a day

Deliver at 37
completed
weeks

Version 2022
 SEVERE PRE-ECLAMPSIA
SBP≥140mm Hg or Proteinuria ≥0.3 g / 24-hour urine
Period of DBP≥90 mm Hg or both specimen or protein/ creatinine ratio
gestation>20 on 2 occasions, 4 hours ≥0.3 (mg/mg) or (30 mg/mmol) in a
weeks apart in a previously random urine specimen or dipstick ≥2+
normotensive patient

Severe Pre-Eclampsia
• BP ≥ 160/110 mm Hg and Proteinuria ≥0.3g/24-hour urine specimen or protein/creatinine ratio ≥0.3 (mg/mg) or (30 mg/mmol) in a random urine
specimen or dipstick ≥2+
OR
• BP ≥ 140/90 mm Hg with danger symptoms like severe headache, blurring, epigastric pain, breathing difficulty and or new onset end organ dysfunction:
– Platelet count <100,000/microL
– Serum creatinine >1.1 mg/dL or doubling from baseline levels
– Liver transaminases at least twice the upper limit of the normal
– Pulmonary edema
– Cerebral or visual disturbances like severe headache, flashes, partial or complete loss of vision

• Urgent hospitalization
• Give MgSO4 as in Eclampsia
• Start anti hypertensive agent if BP≥150/100 mm
Hg. Initiate therapy for acute hypertensive crisis if
BP≥ 160/110 mm Hg as in eclampsia
• Inj Labetalol 20 mg IV bolus, repeat 40 mg after 10
minutes if BP not controlled, repeat 80 mg every 10 minutes if needed (max 300 mg) with cardiac monitoring
OR
• Inj Hydralazine 5 mg IV slowly over 1-2 min, repeat 5-10 mg over 2 min after 20 min. If BP not controlled,
again repeat 10 mg over 2 min (max 20 mg). If no response switch to other antihypertensive drug
OR
• Tab Nifedipine orally immediate release 10 mg stat, repeat 10-20 mg after 20 min. If BP not controlled,
repeat 10-20 mg after 20 min (max 30 mg). {Give through Ryle’s tube if unconscious patient}. If no response
switch to other antihypertensive drug
• Keep record of BP as sometimes there is sudden hypotension
• Continue B.P monitoring every 15 minutes for 2 hours after stabilisation, then every 30 minutes for 1 hour.
Then every hour, if in labour or 4 hours, if not in labour

• Continue Tab Nifedepine 10 mg 8 hourly (max 80 mg/day) OR Tab Labetalol 100 mg 8 -12 hourly (max 2.4 gm/day)
• Investigate — CBC with peripheral smear, platelet count, LFT, KFT, S LDH, Coagulation profile and fundus exam
• Urine output charting
• BP monitoring
• Keep the BP between 130-150 systolic and 80-100 diastolic

Frequency of Investigation
Treatment should be individualised
Parameter Frequency
Hb Alternate days <24 Weeks ≥24 -<34 Weeks ≥34 weeks
Platelets Alternate days

LFT Alternate days or earlier Inj Dexamethasone

Foetal salvage
difficult 6 mg IM repeat
KFT Alternate days or earlier every 12 hrs (Total
Coagulation Profile Weekly profile as needed if 4 doses)
parameters change Offer termination
of pregnancy
Fundus Weekly unless abnormal
BP Controlled
NST/BPP Bi weekly or more if - Explain maternal and foetal
changes seen adverse effect to relatives
- Regular maternal
Doppler Study Weekly or frequent as + foetal surveillance
per the findings
Terminate at 34 weeks
BP Monitoring 4 Hrs

BP Uncontrolled Either induction of labour

- Worsening of clinical/ as per Bishop Score or
biochemical parameters C-section as per
- Signs of foetal compromise the indication

Version 2022
 ALOGRITHM FOR NEONATAL RESUSCITATION
Birth
• Note the time of birth
• Receive baby in dry & warm linen
• Place baby prone on mother’s abdomen

Is the baby Yes Routine Care

crying?
• Continue skin to skin care
• Turn head to one side & wipe
No secretions, if visible
GOLDEN MINUTE

• Dry baby, discard wet linen

• Clamp & cut cord immediately • Cover baby and mother together
• Place under radiant warmer • Clamp & Cut cord between 1-3 mins
• Position head with neck slightly extended • Initiate breastfeeding
• Clear airway by suctioning mouth then nose if required • Check Breathing, Colour and Activity
• Dry baby, discard wet linen
• Stimulate by rubbing the back
• Reposition
Observational Care with Mother
• Place the baby prone between the
mother’s breasts
Breathing well
• Cover baby and mother together

BEYOND GOLDEN MINUTE

Assess Breathing
• Initiate breastfeeding
• Monitor neonate (temperature, heart
Not breathing well rate, breathing and colour, every 15
minutes in first hour and then every 30
• Initiate bag and mask ventilation using room air
minutes in next one hour)
• Give 5 ventilatory breaths and look for chest rise
• If no chest rise after 5 breaths, take corrective steps
• If adequate chest rise, continue for 30 seconds

Assess Breathing
Breathing well
Not breathing well

• Call for help*

• Continue bag and mask ventilation

Assess heart rate

Yes Assess
HR ≥100/min Breathing well Refer to SNCU
Breathing

No
Not breathing well
• Continue bag and mask ventilation with oxygen
• If help* available, then intubate, provide chest
compression and medication if required

• Organize referral to SNCU and continue *Help: A person skilled to provide chest
ventilation (if not breathing well) compression, intubation and medication

Version 2022
CLEANING & STERILIZATION OF OPERATION THEATRE
Spot cleaning
• After each case
–OT Table and surface with aldehyde-based
preparations*/any other suitable disinfectant
recommended concentration as per
manufacture’s recommendation
–Floor and sink with detergent (soap)water/
------hospital grade phenyl (black color)
• High touch surfaces in contact with body fluids
such as surgical light, Boyles apparatus, IV
stand, suction canisters, etc.
• Spills management with 1% hypochlorite
solution (small spill) and 10% hypochlorite
solution (large spill i.e. more than 10 ml)

Daily
• Thorough terminal cleaning and disinfection
including door handles, light switches, all
surfaces, machine equipments & floor mop
Twice a day
• Floor and sinks with detergent (soap) water/
hospital grade phenyl at fixed times
• OT table, table tops and surfaces- light
shades, almirahs, lockers, trolleys with 2%
aldehyde based preparation/any other suitable
disinfectant
Thrice a day
Toilets with aldehyde based high level
disinfectants
Weekly
• Walls, roofs, floors, furniture and fixtures
thoroughly cleaned/washed
• Fogging with silver nitrate and hydrogen
peroxide. Close OT for at least 1 hour (check
literature on chemical for quantity and duration
for closure of space). After fogging, do air
sampling after 1-2 hours and keep records.
Fogging is not required for an OT with a HEPA
filtered positive pressure air supply system
Monthly
• Air sampling should be done on monthly basis
• Air sampling method to be taken by settle plate
method/other air sampling methods
• Random swab sample from surfaces and
disinfected areas
Every 3 months
Microbial water testing to be done every 3 months
and when source changed/major repairs in supply
system/water related outbreak suspected
Linen handling
• Soak blood soiled linen in 0.1% chlorine
solution for 20 minutes
• No rinsing of soiled linen in patient care area
or “toilets”
• Dirty NON SOILED linen and blood soiled
linen to be transported and stored separately
in leak proof bags/containers
After every cleaning
• Disinfect mops by soaking in water with
0.5% hypochlorite solution for 30 minutes.
Wash with detergent and water and dry
in sunlight
• Disinfect buckets and utility gloves with 0.5
% hypochlorite solution for 1 minute
• Wash the utility gloves with soap and water
and hang for drying
• Use separate mop for surfaces and floor
Separate mops for critical areas
General measures
• Personnel entering OT should wear OT
clothes, cap, mask, and shoes all the time
• Proper occlusive clothing of OT personnel
including cap, mask, shoes/slippers and
gown at the time of surgery
• Clean and blood soiled linen to be
transported and stored separately
• Bio medical waste management in OT as
per guideline
• Frequent cleaning of AC filters
*Aldehyde based preparation – are recommended by
guidelines for implementation of Kayakalp. Subject to
availability in the hospital.
Version 2022
 CLEANING & DISINFECTION OF
LABOUR ROOM
Spot cleaning
• After each delivery
– Labour room tables & surfaces with
aldehyde preparations*/ any other
suitable disinfections
– Floor and sink with detergent (soap)
water/hospital grade phenyl (black
color)
• High touch surfaces in contact with
body fluids such as bed rails, IV stand,
bed-side table, etc.
• Spills - management with 1%
hypochlorite solution (small spill) and
10% hypochlorite solution (large spill i.e.
more than 10 ml)
Twice a day
• Floor and sinks with detergent (soap)
water/hospital grade phenyl at fixed
times
• Labour table, table tops & surfaces -
light shades, almirahs, lockers, trolleys in
2% aldehyde based preparation*
• Toilets with disinfectants
Weekly
• Walls, roofs, floors, furniture and fixtures
thoroughly cleaned/washed
Monthly
• Air sampling should be done on monthly
basis
• Random swab sample from surfaces &
disinfected areas
Every 3 months
• Microbial water testing to be done every
3 months and after source changed/
major repairs in supply system/water
related outbreak suspected
*Aldehyde based preparation – are recommended by guidelines for implementation of Kayakalp. Subject
to availability in the hospital.
After every cleaning
• Disinfect mops by soaking in water with 0.5%
hypochlorite solution for 30 minutes. Wash with
detergent and water and dry in sunlight
• Disinfect buckets and utility gloves with 0.5%
hypochlorite solution for 1 minute
• Wash the utility gloves with soap and water and
hang them for drying
• Use separate mop for surfaces and floor. Separate
mops for critical areas
Linen Handling
• Soak blood soiled linen in 0.1% chlorine solution
for 20 minutes followed by rinsing with water
immediately
• No rinsing of blood soiled linen in patient care area
or toilets
• Dirty non soiled and blood soiled linen to be
transported and stored separately in leak proof
bags/containers
General Measures
• Restrict unnecessary entry and use of external
footwear
• LR doctors and paramedics should wear mask, cap
and slippers/shoe covers all the time
• Proper clothing of LR personnel including cap,
mask, slippers/shoe covers and gown at the time
of delivery
• Bio medical waste management in LR as per
guidelines
• Frequent cleaning of AC filters
Version 2022
 Disinfection & Sterilization of Equipment
Wear Utility Gloves

Decontaminate the instruments in 0.5 % sodium

hypochlorite solution for 10 minutes

Cleaning : Soak the instruments in water

(Soak the instruments in water with detergent immediately after use
or keep the instruments in a bucket and cover with wet towel)

Thoroughly wash and rinse instruments

Preferred Method Acceptable Method

Sterilization High Level Disinfection (HLD)

CHEMICAL AUTOCLAVE BOIL OR STEAM CHEMICAL

z Soak in 2% z 15 pounds z Lid on, 20 z Soak in 2%

activated pressure, 121ºC minutes after activated
Glutaraldehyde z 20 minutes for water boils Glutaraldehyde
solution for a unwrapped z Articles should solution for a
minimum of instruments be completely minimum of
10 hours immersed 20 minutes
z 30 minutes for
z Rinse with wrapped in water z Rinse with
sterile water* instruments z Do not add or sterile/HLD
and dry remove more water and dry
z Used for linen
z For e.g. (30 min) instruments z For e.g.
endoscope, after the water endoscope,
z Used for cotton,
laparoscope, starts boiling laparoscope,
instruments
sharps z Used for sharps
and surgical
*(For sterile water, leftover dressing instruments
water from Autoclave may be
used)
(20 min)

1. Autoclaved instruments can be used upto 7 days if drum is not opened .

2. Unused Autoclave instruments are to be re-sterilized after 24 hours, once drum is opened.
3. Instruments processed with wet methods (boil/steam) are to be re-sterilized after 24 hours,
if unused.

Labelling of sterilized sets to include Autoclave number (if more than 1 Autoclave in the hospital), batch/cycle
number, date of sterilization, expiry date, technician name and Chemical Indicator (Signiloc).

Version 2022
 ARE YOU TRANSFERRING HARMFUL
GERMS WITH YOUR HANDS?
Always wash hands or use hand rub at critical times
to prevent health care associated infections
When to wash hands?

1
Before touching
the patient
2
Before clean/septic
procedures
5
After touching
the patient

4
After touching
the patient
surface/items 3
After body
fluid exposure/
risk

Hand wash Alcohol hand rub Nails Remove

(40-60 seconds)
-To be done before and
after every clean/aseptic
procedure
-When hands are visibly dirty
and/or in contact with
body fluids.
(20-30 seconds) trimmed jewellery
-To be done before and after
touching the patients’ and its
surrounding, surface, items
like bed, rails, bed side
table, etc.

Version 2022
 6 STEPS OF HAND WASHING
Wet hands with running water, apply soap, lather well as per the steps mentioned below
(40-60 seconds for the entire process)

1 2 3

Rub hands palm to palm Rub back of each hand with palm Rub palm to palm with
of other hand with fingers crossed
fingers crossed

4 5 6

Rub with back of fingers to Rub each thumb clasped in Rub tips of fingers in opposite
opposing palms with opposite hand using a palm in a circular motion
fingers linked twisting movement

INSTRUCTIONS
• Wet hands with water • Rub each wrist with opposite hand
• Apply enough soap to cover all hand surfaces • Rinse hands with water

Hand washing with soap and running ENSURE THE FOLLOWING

water is mandatory   Nails should be trimmed
• Before and after every procedure  All ornaments (rings, bangles, watch) should
• When hands are visibly dirty be removed
• Contact with body fluids
 Dry your hands in air or with single use towel
(if available)
Version 2022
 BIOMEDICAL WASTE MANAGEMENT RULES, 2016 (AMENDED 2018 & 2019)
Yellow Category Red Category Blue Category White (Translucent)
Non-chlorinated plastic bag/container Non-chlorinated plastic Puncture proof and leak Puncture proof, leak proof,
bag/container proof container with blue tamper proof container
coloured marking

Handle WitH Care

Handle WitH Care Handle WitH Care

Handle WitH Care

Handle WitH Care Handle WitH Care Handle WitH Care
Handle WitH Care Handle WitH Care

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Human and animal anatomical wastes Cytotoxic drugs Recyclable waste (plastic) Waste metal sharps
Tissues, organs, body parts and Items contaminated Tubing Used, discarded and
fetus below the viability period
Waste glassware
with cytotoxic drugs Bottles contaminated needles
Broken glass
Soiled waste IV tube/sets Syringes with fixed needles
Contaminated with blood, body Medicine vials/ampules
Catheters Needles cut in hub-cutter
fluids like dressings, swabs, plaster
Metallic body implants scalpel blades
casts, linen, pads, mask and gown Urobags
Blood bags Syringes
Pre-treated before putting it in
yellow containers Vacutainers
Chemical wastes Gloves Note- All Plastic bags should
Including discarded disinfectants,
chemical liquid wastes be as per BIS Standard and
Lab wastes all Plastic bags should be
Lab cultures, dishes and devices used for culture properly sealed when 3/4th
Onsite treatment before putting in yellow container
full, labelled and recorded
Expired/discarded medicines
before disposal.
Discarded linen/mattresses
Discarded linen/mattresses beddings contaminated with blood or body fluid, routine mask and gown Version 2022
 Antenatal
Checkup jk"Vhª; xkzeh.k LokLF; fe’ku

l Helps in identifying complications of pregnancy on time and their management

l Ensures healthy outcomes for the mother and her baby
l Necessary for well-being of pregnant woman and foetus Registration and
4 minimum
Provide ANC Antenatal Checkups
whenever a during pregnancy
Supplementation woman comes
and more if indicated
during Pregnancy
for Registration & In first 12 weeks
l Folic acid tab 400 µg 1st ANC of pregnancy
daily in Ist trimester check up
Between 14 and
2nd ANC
26 weeks
l Iron Folic acid tab daily
from 14 weeks onwards 3rd ANC
Between 28 and
34 weeks
l For Anemic women, Iron
Between 36
Folic acid tab twice daily 4th ANC weeks and term

First Visit At All Visits

l Pregnancy detection test l Physical examination
l Fill up MCP Card and ANC register l Abdominal palpation for
l Give filled up MCP Card and Safe Motherhood booklet foetal growth, foetal lie
to the woman and auscultation of foetal
l Past and present history of any illness/complications heart sound
in this or previous pregnancy
Investigations
l Physical examination (weight, BP, respiratory rate)
l Hemoglobin estimation
and check CVS/Resp system, breast, pallor, jaundice
l Urine exam for protein, sugar
and oedema
and micro exam
l Two doses of Inj. TT 4 weeks apart whenever
l At 24–28 weeks blood sugar
pregnancy is detected
(OGCT)– 2nd or 3rd visit
Investigations
Counselling for
l Hb%, urine examination
l Adequate rest, nutrition and
l Blood group including Rh factor
balanced diet
l RPR/ VDRL, HBsAg, HIV screening
l Recognition of danger signs
l RDK test for malaria (in endemic areas)
during pregnancy, labour and
Information for pregnant woman and her family after delivery or abortion and
l Encourage institutional delivery/ensure delivery by signs of normal labour
identification of SBA l Initiation of breastfeeding
l Explain entitlement under JSSK & JSY immediately after birth
l Identify the nearest functional PHC/FRU for delivery l Counselling for small family
l High risk pregnancy to be attended in District Hospital norm
and Medical College l Use of contraceptives (birth
l Pre-identification of referral transport and blood donor spacing or limiting) after
birth/abortion
For use in medical colleges, district hospitals and FRUs
 Postnatal
Care jk"Vhª; xkzeh.k LokLF; fe’ku

Post natal
1st Check up 1st day of delivery
care
2nd Check up 3rd day of delivery
ensures
3rd Check up 7th day of delivery
well-being
of the 4th Check up 6 weeks after delivery

mother and Additional check ups for

the baby Low Birth Weight babies on
14th, 21st and 28th days

SERVICE PROVISION DURING CHECK UPs

Mother Newborn

l Heavy bleeding l Confirm passage of urine (within

l Breast engorgement 48 hours) and stool (within 24 hours)
Ask
l For convulsions, diarrhea and
vomiting

l Pallor, pulse, BP and l Activity, color and congenital

temperature malformation
l Urinary problems and l Temperature, jaundice, cord stump
Observe perineal tears and skin for pustules
& Check l Excessive bleeding (PPH) l Breathing, chest in drawing
l Foul smelling discharge l Suckling by the baby during breast
(Puerperal sepsis) feeding

l Danger signs l Keeping the baby warm

l Correct position of breast feeding l No bathing on first day
and care of breast and nipples l Keep the cord stump clean and dry
l Exclusive breast feeding for l Additional check up for the Low Birth
Counsel 6 months Weight babies
l Nutritious diet and calcium rich
For foods
l On importance of Routine
Immunisation
l Maintaining hygiene and use of l Danger signs in baby
sanitary napkins
l Choosing contraceptive method

l Hb% estimation l Give 0 dose BCG, OPV, Hepatitis B

Do l Give IFA supplementation to the l Give Inj. Vitamin K 1 mg IM
mother for 3 months

For use in medical colleges, district hospitals and FRUs

 Management of
Atonic PPH
l Placenta expelled, uterus soft and flabby
l Traumatic causes excluded

l Shout for help, Rapid Initial Assessment
to evaluate vital signs: PR, BP, RR and
Temperature
l Establish two I.V. lines with wide bore
cannulae (16-18 gauge)
l Draw blood for grouping and cross
matching
l If heavy bleeding, infuse NS/RL 1L
in 15-20 minutes
l Give O2 @ 6-8 L /min by mask,
Catheterize
l Check vitals & blood loss every
15 minutes, Monitor input & output

l Perform continuous uterine massage

l Give Inj. Oxytocin 20 IU in 500 ml RL/ NS @ 40 drops/minute
l Do not give Inj. Oxytocin as IV bolus

Uterus still not contracted

If bleeding P/V not controlled

Inj Ergometrine* 0.2 mg IM or IV slowly (contraindicated in high BP, severe anemia, heart disease)

Inj Carboprost* (PGF2) 250 µg IM (contraindicated in Asthma)

If bleeding P/V not controlled

Tab Misoprostol (PGE1) 800 µg Per rectal

Bleeding not controlled by drugs Bleeding controlled by drugs

l Repeat uterine massage every 15 minutes

for first 2 hours
Explore uterine cavity for retained placental bits
l Monitor vitals closely every 10 minutes for
30 minutes, every 15 minutes for next
30 minutes and every 30 minutes for next
3-6 hours or until stable
l Perform bimanual compression
l If fails perform compression of abdominal
l Continue Oxytocin infusion (Total Oxytocin
aorta not to exceed 100 IU in 24 hours)

l Check for coagulation Uterine Tamponade Surgical intervention

defects (Indwelling Catheters/
l If present give blood Condom/ Sangstaken tube/
products Ribbon gauze packing) as
life saving measure
l Uterine compression
suture (B-Lynch)
l Uterine/Ovarian A ligation
l Hysterectomy

Continue vital monitoring Transfuse blood if indicated Monitor Input/ Output

* Wherever needed
Inj. Ergometrine can be repeated every 15 minutes (max 5 doses =1 mg) Inj Carboprost can be repeated every 15 minutes (max 8 doses= 2 mg)

For use in medical colleges, district hospitals and FRUs

 Active Management of
Third Stage of Labour
(AMTSL)

l Mandatory for all deliveries (vaginal and abdominal)

l Exclude presence of another baby after delivery of first baby

Step 1 Inj. Oxytocin 10 units IM immediately after birth

Step 2 l Controlled cord traction once uterus is contracted

and cord is cut
l Apply cord traction (pull) downwards and give
counter-traction with other hand by pushing
uterus up towards umbilicus

Step 3 Uterine massage to keep uterus contracted

For use in medical colleges, district hospitals and FRUs

 Breastfeeding

l Start
breastfeeding
within 1 hour
of delivery
l Feed on demand

l Feed completely
on one breast,
then shift to
other breast

Correct Attachment
Baby well attached to the mother’s breast
l Chin touching breast
l Mouth wide open
l Lower lip turned outward
l More areola visible above than below
the mouth

Exclusive
breastfeeding
for 6 months;
continue
breastfeeding
for 2 years Wrong Attachment
Baby poorly attached
to the mother’s breast

For use in medical colleges, district hospitals and FRUs

 Antenatal
Examination
FUNDAL HEIGHT

Preliminaries
36wk
Xiphisternum
l Respect woman’s rights 40wk
32wk
l Explain procedure and ensure
privacy 28wk

l Ensure bladder is empty 24wk Umbilicus

l Examiner stands on right side 20wk

l Abdomen is fully exposed from 16wk

xiphisternum to pubis symphysis
12 wk Pubis Symphysis
l Keep woman’s legs straight (Uterus becomes
an abdominal organ)
l Centralise uterus
Symphsio-fundal height in
cms corresponds to weeks
of gestation after 28 weeks

Correct dextrorotation Ulnar border of left hand is placed on upper Measure distance between
most level of fundus and marked with pen upper border of pubic
symphysis and marked point

GRIPS

Legs are slightly flexed and separated for obstetrical grips

Fundal Grip Lateral Grip

Foetal heart sound is usually located along the lines

First Pelvic Grip Second Pelvic Grip as shown

For use in medical colleges, district hospitals and FRUs

 Vaginal Bleeding
jk"Vhª; xkzeh.k LokLF; fe’ku

(Before 20 Weeks)
Light Bleeding Heavy Bleeding Any Bleeding with

l Mild pain l Mild pain l Severe pain l H/O expulsion of Product of Conception H/O passage l Pain
l No H/O expulsion of l H/O expulsion of l Uterus normal l Uterine size < Period of Gestation of vesicles l H/O interference
Product of Conception Product of size/bulky l Os may be open
l Uterus size Conception l Tenderness in
corresponds to Period l Uterus normal size/ fornix/mass
of Gestation bulky Vesicular mole Septic abortion
l Os closed l Os closed Incomplete / Inevitable abortion

Complete abortion Ectopic pregnancy

Threatened abortion l Broad spectrum
Confirm by UPT and USG Confirm by USG
l Rapid Initial Assessment
IV Antibiotics
l Resuscitate if in shock l USG
Manage as ectopic
USG Observe and follow up
pregnancy

Transfuse blood if needed l S.

S.HCG
HCG l Evacuate uterus
Foetus viable Bleeding persists – Foetus not viable
l Chest X-ray l Laparotomy if
repeat USG for foetal
viability after 1 week l TVS for theca- bowel injury/
Threatened abortion Missed abortion lutein cyst cyst
thecalutein pyoperitoneum
Uterus <12 wk size Uterus >12 wk size

l Reassure Uterus <12 wk size Uterus >12 wk size

l Rest and
abstinence Misoprost 400 mcg Manual Vacuum l Start 10-20 U Manual Vacuum
Manual Vacuum
Aspiration/ Electric oral 4 hourly max Aspiration/ Oxytocin in Aspiration/
Vacuum Aspiration 5 doses (2000 mcg) Electric Vacuum 500 ml NS/RL @ Electric Vacuum
Bleeding Aspiration 40-60 drops/min Aspiration
stops –
routine Check for completeness l Evacuate uterus
ANC
If still bleeding-MVA/
EVA/check curettage Follow up as mole

Counsel to avoid pregnancy for at least 6 months Advise contraception

For use in medical colleges, district hospitals and FRUs
 Antepartum Haemorrhage
(Vaginal bleeding after 20 weeks) jk"Vhª; xkzeh.k LokLF; fe’ku

l Rapid Initial Assessment– monitor PR, BP, RR l Ask for pain; check for uterine contour/tenderness l Arrange & transfuse blood if needed
l Resuscitate if necessary and start IV fluids l Exclude local causes by P/S examination l Confirm diagnosis by USG if available

Placenta Previa Abruptio Placentae Rupture Uterus

No PV to be done

Immediate LSCS Expectant Management LSCS ARM + Oxytocin l Bleeding PV light/moderate

l Bleeding PV heavy and
continuous irrespective
of gestational age
l Term pregnancy with
Type II post, III, IV
placenta
l Dead/Malformed foetus
(irrespective of POG)
with Type III and IV
placenta
l Term pregnancy with
malpresentation or other
obstetric indication
l Bleeding PV light/stopped l Heavy bleeding PV l Bleeding PV light/ l H/o labor followed by sudden cessation of pains
l POG < 37 weeks with vaginal moderate l Previous LSCS
delivery not l FHS normal l Tender abdomen
l Live baby, no gross foetal
imminent
anomaly l Dead foetus l Loss of uterine contour
l Fetal distress
l Women not in labor l FHS absent
l Foetal parts superficially palpable
l Hospitalize
Monitor for
l Correct Anemia
l Arrange Blood l Hemorrhage and
l Feto-maternal surveillance shock Laparotomy and repair of uterus/Hysterectomy
l Steriods if POG < 34 weeks l Coagulopathy
l Renal failure

l Terminate if 37 weeks or persistent/heavy bleeding PV

l P/V under double set up in OT

Type I, II Ant Type II post, III and IV

l ARM + Oxytocin l LSCS
l Deliver vaginally

If previous LSCS with Placenta previa keep Placenta accreta in mind Be prepared for PPH in all cases of APH
For use in medical colleges, district hospitals and FRUs