O&G HO GUIDE @thechayondeducation

LABOUR ROOM
(HO GUIDE)
O&G HO GUIDE @thechayondeducation

TRANSFER IN REVIEW

12/01/22 How many reviews usually in labour

1350H room?

a. Transfer in review
39 years old, G1P0 at 38 weeks + 1 day POA b. Review every 4 hours
LMP: 18/02/21 c. AM review
EDD: 25/11/21 d. Postnatal review (1 hour
post-delivery)

Transfer in from Ward 24 for active phase of labor/favorable BISHOP

ANC
1. Active phase of labor
- Contraction pain associated with show since 0830H yesterday

Currently, contraction 2:10; in 30 secs, 2 hours in labor

no leaking
no show
on IV Pitocin 32cc/hr

O/E, alert, pink

Time contraction
BP: 128/77 4:10:45 Primid
PR: 88 3-4:10 Multipara
RR: 20 3:10:45 Prev scar
T: 37
Lungs: Maximum Pitocin
CVS: 8 mu/min Prev scar/
Grandmultip
P/A, soft, non-tender 16 mu/min Others
Uterus at termed 32 mu/min Primid
Singleton, cephalic
Head 3/5th
EFW 3.2 – 3.4 kg

VE: VVNAD
Cervix 0.5cm, mid-anterior, soft
Os 4 cm
Station -2
Membrane intact. ARM done at 1400H – CL
Vertex, No cord/placenta

Plan
1. CTG STAT post ARM
2. Continue CTG Monitoring with 2 hourly tracing
3. Time contraction ½ hourly, aim contraction 4:10 in 45 secs. If suboptimal, for IV Pitocin augmentation,
provided CTG normal
4. For s/c Nubain 10 mg STAT and 6 hourly provided CTG normal
5. For IV Drip 1 pint NS over 4 hours
6. NR contraction in 2 hours 1600H
7. NR in 4 hours 1800H
8. Continue vital signs monitoring
O&G HO GUIDE @thechayondeducation

POST NATAL REVIEW (2 hours post-delivery)

12/01/22
2200H What to prepare?

1. Tali pad
39 years old, Para 1, delivered at 38 weeks + 1 day POA 2. 2 Pads
2 hours post SVD with intact perineum 3. Acriflavin
EBL: 200 cc 4. Cream
5. Chlorhexidine
Delivered baby boy @2000H, BW 3.5 kg with good APGAR score 6. Cotton

Baby was discharge to mother

ANC
1. GDM on diet control

Currently, no anemic symptoms

tolerating orally
afebrile
no excessive bleeding
pad half soaked

O/E, alert, pink

BP: 128/77
PR: 88
RR: 20
T: 37

P/A, soft, non-tender

uterus contracted at 20 weeks
no calf tenderness

VE: VVNAD
No hematoma
No foreign body
Suture intact
Minimal blood clot

PR: Good anal tone

No suture felt

Pad half soaked Refer/Inform paediatric

1. EMLSCS (reason,
VTE: 0 gestational age, EFW)
2. Thick meconium
Plan 3. Instrumental deliveries
1. T/O to postnatal ward 4. SGA/Macrosomic/Fetal
abnormalities
2. Monitor vital signs 4 hourly 5. GDM on treatment
3. Strict pad charting – to inform if increase in PV bleed
4. Measure first void urine
5. Encourage orally, ambulation and breastfeeding

AND don’t forget to check, document, and refer baby if indicated.

O&G HO GUIDE @thechayondeducation

COMMON PLAN IN LABOUR ROOM

1. Active phase of labour (uneventful)

- Monitor vital signs 4 hourly
- Time contraction ½ hourly
- Observe contraction for 2 hours, aim 4:10, 45 seconds, if suboptimal for IV Pitocin
(max 8/16/32mU/min) provided CTG is reactive (8mU/min in grand multipara and previous scar)
- CTG stat post ARM
- Continuous CTG monitoring with 2 hourly tracing
- For IV drip 1 pint NS over 4 hours
- For IM Nubain 10mg stat and 6 hourly
- Next review in 4 hours at 1630H

2. 1 previous scar
- Monitor vital signs ½ hourly
- Watch out for scar dehiscence

3. Preterm labour (not for ARM, only SROM)

- Allow labour to progress
- Next review when patient complains of bearing down
- To refer paeds post-delivery (if very preterm, inform paeds to book ventilator)

4. Chronic hypertension with superimposed pre-eclampsia (mother condition, baby, drug, others)
- Monitor vital signs ½ hourly
- Daily urine albumin
- Watch out for IE symptoms
- Continue Tab Nifedipine 10mg TDS
- To start IV MgSO4 if BP uncontrolled
- For IM Dexamethasone 12 mg stat and 12 hours later
- Monitor FHR
- Time contraction
- NBM with total IV drip of 1cc/kg/hour (max 80cc)

5. Severe pre-eclampsia
- Monitor vital signs ½ hourly
- Continue IV MgSO4 infusion to complete for 24 hours at 1245H today
- MgSO4 toxicity chart 2 hourly
- Strict I/O chart
- Monitor FHR
- Time contraction
- NBM with total IV drip of 1cc/kg/hour (max 80cc)
- Next review at ...
- If stable, allow clear fluid, then nourishing fluid then orally

6. PROM/PPROM >18 hours

- Continue IV Benzylpenicillin 1.5g 4 hourly
- If >18 hours in LR, start IV Benzylpenicillin 3g stat and 1.5g 4 hourly
- Watch out for chorioamnionitis
- Refer paeds after delivery
O&G HO GUIDE @thechayondeducation

7. GDM mother in labor

- GM STAT on admission, if GM within 4-7, for GM 4 hourly
- if >7 mmol/L, repeat GM in 1 hour, if persistently >7, start sliding scale
OR if >10 mmol/L on admission, start sliding scale
- If intrapartum GM <4 mmol/L: symptomatic – IV D50% 20cc bolus, asymptomatic – nourishing fluid

8. Anemia in pregnancy
- Delay or avoid episiotomy
- If needed, for rapid proper repair of episiotomy wound
- Active management of 3rd stage of labor

9. Contraction in labour
- Primid and pseudoprimid (aim contraction 4:10;45seconds)
- Multipara (aim contraction 3-4:10;45seconds)

10. Analgesic in labour

- Os 4-7cm (IM Nubain 10mg stat and 6 hourly)
- Os 7cm and above Entonox only, prevent drowsiness of Nubain to baby
- IV Paracetamol 1g stat and 6 hourly (study)

11. History of abortion

- Significant only if recurrent (especially 1st trimester)
- History of D&C done (risk of adherent placenta)

12. Patient IOL

- Start Pitocin once CTG reactive
- Beware start only after 6 hours of last Prostin dose

13. Active phase of labour

- If contraction 4:10, 20 seconds, start IV Pitocin only after 2 hours
- If IOL case, start IV Pitocin immediately after CTG post ARM reactive (oligo, SGA, MSL, post EDD)
(to expedite delivery)

14. Signs of obstructed labour

- Head 1/5th
- Cervix swollen
- Caput
- Molding

15. Active 3rd stage management

- Uterine massage
- IM Syntometrine/IM Pitocin 10 units
- Early cord clamping
- CCT

16. Pitocin dilution

- 1 ampoule = 10 units = 10000mU
- 3 units = 3000 mU/50cc = 60 mU/cc (1cc ad 60mU)
- 1cc/hour= 60mU/h =1mU/min
(max in primid 32mu/min)
(max in multipara 16mu/min)
(max in 1 previous scar and grand multipara 8mu/min (only after 2 hours) )
O&G HO GUIDE @thechayondeducation

17. Resus baby

- Call paeds standby and JM resus room
- Put green cloth head below
- Stimulate
- Suction
- EFW >3kg = size 10 (purple)
- EFW <3kg = size 8 (blue)
- PREM = size 6 (green)
- Check FHR in 6 seconds at umbilical cord and x10
- O2 2L/min
- CPAP use 10 L

18. Baby resus

- Prepare cloth, O2 and suction
- Baby flat, call NICU for standby, calculate heart rate in 6 seconds X10
- If less than 60, CPR
- If thick meconium, intubate and do direct suction
- Laryngoscope prem 00, term 0
- ETT size 3,3.5
- Stimulate baby
- Give oxygen
- Wipe and remove cloth, replace new one

19. Bleeding previa preterm

- Refer paeds to book ventilator (risk of LSCS if bleeding again)

20. Uterine inversion

- Neurogenic shock due to vagal stimulation of associated nervous tissue contained in the uterine
ligaments leading to bradycardia and hypotension, but be prepared for hemorrhagic shock
- Management:
- Resuscitation
- Uterine reposition
- O Sullivan’s hydrostatic method (using silicone cups with 5-10L of NS)
- Manual reduction
- Remove placenta once uterine had been reposited by MRP
- Next delivery must be in tertiary hospital with trained personnel

21. Conservative management even if cord prolapse in

- IUD
- Anencephaly

22. Instrumental delivery

- Indication
- Maternal (power) – maternal exhaustion, inadequate power (spinal cord injury/neuromuscular disease),
prevention of prolonged labor (hypertensive crisis and cerebrovascular disease)
- Fetal (fetal distress, fetal malposition, delivery of head in breech delivery (ABD), prolonged second
stage)
- Types
- forceps (levelburn, Wrigley’s)
- vacuum
- Criteria
O&G HO GUIDE @thechayondeducation

- Os must be fully dilated

- membrane must be ruptured
- head must be engaged
- OA or OP position
- lithotomy position
- bladder empty
- episiotomy
- anesthesia given
- Complications
- Maternal (uterine, cervical, or vaginal laceration, extension of episiotomy, urethral injury, hematoma)
- Fetal (cephalohematoma, bruising and laceration, skull fracture and intracranial bleed, facial nerve and
brachial plexus palsies)

23. Subcutaneous Bricanyl (Terbutaline)

- B2 agonist used for uterine hyperstimulation
- 1 ampoule contains 1cc/0.5mg
- take 0.5cc (0.25mg=250mcg) using 1cc syringe and give to patient

24. Shoulder dystocia (HELPERR)

- Call for Help
- Evaluate for Episiotomy
- Legs – McRoberts maneuver (knee chest position)
- Suprapubic Pressure
- Enter the pelvis and rotational maneuver
- Rubin 2
- Cockscrew
- Reverse cockscrew
- Remove Posterior arm
- Roll over on her hands and knees

25. Primary PPH

- Call for help, ABC and 2 large bore branula
- Take FBC, RP, LFT, coagulation profile, GSH/GXM
- Vital signs monitoring
- Run fast IV drip 1 pint NS/Hartmann (suitable for resus less risk of acidosis, by product of lactate
metabolism in liver counteract acidosis)
- Check uterus contracted or not. If contracted, exclude tissue, thrombin, and trauma. If not contracted,
- Uterine massage
- Uterotonic agents (IM Pitocin, IM Syntometrine, IM Hemabate 250mcg up until 8
times/intramyometrium), IV Pitocin 40units in 1 pint NS, IV Duratocin 100mcg) 3IM2IV.
- If fail, Bakri’s balloon, and iliac artery ligation
- IV Duratocin is longer acting and weaker compared to oxytocin, preferred in patient with previous scar
and multipara

26. Secondary PPH

- Abnormal of heavy per vaginal bleed between 24 hours and 12 weeks after birth
- Retained POC
- Endometritis
O&G HO GUIDE @thechayondeducation

27. Risks of PPH

- Grand multipara
- Polyhydramnios
- Abruption placenta
- Precipitate labor (<3hours)
- Multiple pregnancy
- Pregnancy with uterine fibroid
- Macrosomic baby

28. APH when to deliver

- Weigh the risk of prematurity and risk of bleeding. If bleeding at term, just go for Caesar

29. Macerated stillbirth grade

- Grade 1 – reddened skin (6-8hours)
- Grade 2 – skin slippage and peeling (8-12hours)
- Grade 3 – extensive skin peeling, red serous effusion in chest and abdomen, liquefaction of inner
structures like brain

30. Abnormal labour / dystocia causes divided into three:

- Power
- Passenger
- Passage

31. Poor labor progress

- Primary dysfunctional labor • 1st stage – latent phase >20hours, <0.5-1.0cm per hour in labor, 2nd stage
- >2 hours primigravida, >1 hour in multipara
- Secondary arrest – 1st stage – Os cease to dilate, 2nd stage – large caput, excessive molding, edematous
vulva

32. Management of poor labor progress

- Prolonged latest phase – Analgesic (pain increase sympathetic activity which reduce uterine smooth
muscle contractility)
- Prolonged active phase – Amniotomy, Oxytocin augmentation

33. Meconium stain liquor paediatrics referral

• Signs of respiratory distress – grunting, nasal flaring, intercostal/subcostal recession, plethoric face
(read: Silverman scoring)
• Meconium covers body, suction meconium or not.

34. PROM>18hours Paeds referral

• Septic parameters: mother vital signs, TWC, CRP
• Liquor color
• HVS/LVS
• IV Benzyl penicillin given how many doses

35. Continuous morphine infusion (CMI) patient

• Need CBD
• Need drip 1pint in 24 hours

36. Prophylactic antibiotics for forceps and vacuum for EUA

• IV Cefuroxime 1.5g stat and 750mg TDS
• IV Flagyl 500mg stat and TDS
O&G HO GUIDE @thechayondeducation

37. Hypertension in pregnancy

Management of Impending Eclampsia

IV Magnesium Sulphate (seizure control) – 1 ampoule = 2.47g of MgSO4/5cc

a. Loading dose
• 4g (8cc) MgSO4 in 12cc NS
• 20 cc syringe
• Give 10-15 minutes slow bolus
• Or IM 5g(10cc) with 10cc syringe given in each buttock with LA (total 10g)

b. Maintenance dose
• 10g(20cc) MgSO4 in 30cc NS
• Use 50cc syringe
• Give IVI MgSO4 1g(5cc)/hour over 24 hours
• Or IM 5g(10cc) with 10cc syringe given in alternate buttock with LA 4 hourly

c. MOA
• Causes cerebral vasodilatation
• Rapid bolus – cardiac arrest, respiratory depression

d. Toxicity correction (BURP)

• IV Calcium Gluconate 1g 10% 10cc over 3 minutes

e. Pathophysiology of APO
• Due to increased vascular permeability, decrease in protein (protein losses in urine)

f. Tab Labetalol
• Max dose 400mg BD
• 100, 200, 300mg TDS doses

38. Management of severe hypertensive disorder in pregnancy (BP control)

a. Labetalol infusion
• Rapid control
- IV Labetalol 10mg (2cc) over 1 minute
- Repeat after 15 minutes interval
- May repeat up to 4 boluses
- Maximum 200mg(40cc)
• Infusion pump
- 200mg Labetalol in 50cc syringe
- Start at 20mg/hour or 5cc/hour
- Increase every 30 minutes of 5cc/hour (e.g., 5,10,15), stop if the rate exceeds 150mg/hour or infusion
>6 hours
b. Hydralazine infusion
• Rapid control
- IV Hydralazine 5mg over 5-10 minutes
- Repeat every 15-20 minutes if DBP>90mmHg
- Cumulative dose: 20mg (4 doses)
- Dilute 20mg in 20cc NS give 5cc over 5-10 minutes
• Infusion pump
- Dilute 25mg Hydralazine in 50cc NS
O&G HO GUIDE @thechayondeducation

- Starts at 5cc/hour
- Increase every 15 minutes by 1 cc
- Max dose: 10cc/hour or 10mg/hour
• Drip set
- dilute 25mg Hydralazine in 500cc NS
- Start at 10dpm and increase every 15 minutes
- Titrate against DBP
- Maintain dose if DBP 90-100 mmHg for 2-3 reading. If control, then reduce BP dose slowly

39. Chronic HPT patient in BP crisis

• Aim MAP <125mmHg
• Aim BP < 160/100mmHg
• Monitor urine output in MgSO4
- not less than 100cc/4hours
- not less than 20cc/hour
- 0.5-1.0cc/kg/hour
- if oliguric, challenge with 200cc NS over ½ - 1 hour as it might cause waste retention

40. Eclampsia mother general condition

• A – alert
• V – respond to voice
• P – respond to pain
• U – unresponsive

41. Severe PE for LSCS

• Don’t give fluid 4 pints NS
• Reduce to 70/75cc (1cc/kh/hr max 80cc/hr)

42. BP aim post delivery

• <140/90 mmHg
• Risk of eclampsia higher in 24 hours post delivery

43. Pre-eclampsia profile

• EDTA – FBC
• Plain bottle – RP, LFT, uric acid
• Urine FEME, UPCI
• 24 hours urine protein (when UPCI>30)

44. Severe PE
• Placenta insufficiency causing IUGR is one of the TOD

45. Pre-eclampsia post EMLSCS (clinical and biochemical)

• Problem listing (latest investigation if available)
• Currently,
- no IE symptoms
- able to pass flatus
- normal urine output (0.5-1.0cc/kg/hour)
- tolerating orally, tolerable pain
• On examination
• Normal Mg value – 1.7 – 3.5
• For PE charting
• For MgSO4 toxicity charting
• 2 hourly MgSO4 toxicity charting
O&G HO GUIDE @thechayondeducation

46. Young hypertension

Hypertension that develops in individual <35 years old
• Need to rule out secondary causes
• Serum renin, serum aldosterone and ANA

47. Eclampsia
Call for help, ABC and 2 large bore branula
• Take FBC, RP, LFT, uric acid, GSH
• IV/IM MgSO4 bolus and maintenance
• if still not aborted, IV MgSO4 2g(4cc) bolus
• Start antihypertensive if DBP> 110mmHg or MAP> 125mmHg
• NBM with total IV drip 1cc/kg/hour
• Monitor FHR
• Plan for delivery

48. HELLP syndrome

49. History of pre-eclampsia in previous pregnancy

• ask if treated with MgSO4 or not
• indicates severity

50. Principles of management of pre-eclampsia

• BP control
• Prevent caesarean section
• Monitor mother and fetus
• Strict fluid monitoring
• Time of delivery

51. Definition of pre-eclampsia

• BP >140/90mmHg after 20 weeks gestation with one of the following
• Persistent proteinuria
• TOD

52. Normal uric acid value

• Gestational week x 10
• e.g., 34weeks x 10 = 340

53. Principles of management heart disease in pregnancy (find Heart Disease Guideline 2016)
• Pre-pregnancy counselling
• Status determination/severity
- symptomatic
- asymptomatic
• Risk stratification
- mild
- moderate by symptoms and echo?
- severe
• Refer to cardio. If severe, consider TOP

54. Persistent proteinuria in KK

• KK must have done:
- EOD BP monitoring
- 24 hours urine protein collection

55. Methyldopa
O&G HO GUIDE @thechayondeducation

• Can cause postpartum depression due to centrally acting

• Can cause somnolence if use in late pregnancy or postpartum

56. HELLP syndrome

• Start venturi mask and regular ABG to look for acidosis and gas partial pressure level

57. Pathophysiology of pre-eclampsia

• Consumptive thrombocytopenia
• Placenta insufficiency -> oxidative stress -> release mediators -> thromboxane A2 and prostacyclin
imbalance
• thromboxane A2 – vasoconstriction
• prostacyclin – vasodilatation
- that’s why give low dose aspirin in high risk patient
- endothelial injury + low protein -> oedema

58. Syrup lactulose 15mls ON

59. Pre–eclampsia patient for IVI MgSO4

• Must insert CBD for urine output
• 2 hourly MgSO4 toxicity charting
• Medication
• Aim BP
• Total IV drip
• Watch out IE symptoms
• Must keep in ward for at least 5 days after completed (VTE score usually up by 1 prolonged stay)

60. PE plan in labor room

• Monitor vital signs half hourly
• Aim BP <140/90
• Continue Tab Labetalol
• Continue IV MgSO4 infusion with 2 hourly toxicity charting
• Total IV drip 1cc/kg/hour
• Watch out for IE symptoms
• Strict I/O charting

61. Post EMLSCS plan

• Strict pad charting, to inform if increase PV bleed
• For TED stocking
• for SC Heparin/Clexane
• Encourage orally, ambulation and EBM
• WI D3

62. High risk consent

• Risk and complications of LSCS explained
• In view of patient just had meal (less than 6 hours) on 2200H
• High risk of aspiration pneumonia
• Patient understood and agreed for operation
• To proceed with EMLSCS as planned

63. Complications for pre-eclampsia (head to toe)

• Eclampsia
• Intracranial bleed
• Posterior reversible encephalopathy syndrome (PRES)
• acute pulmonary oedema
O&G HO GUIDE @thechayondeducation

• subhepatic hematoma
• hepatorenal syndrome
• HELLP
• DIVC
• abruptio placenta
• IUGR

64. Management of Impending eclampsia

• Stabilize BP
• IV MgSO4 4g STAT loading dose with 2 hourly toxicity monitoring
- Loss of deep tendon reflexes
- Diminished urine output <30 ml/hr
- Respiratory depression
• Close monitoring of vital signs: ½ hourly BP, strict IO charting
• Take PE profile
• GSH
• For IM Dexamethasone 12 mg STAT and 12 hourly x 1/7 (If preterm)