Bwa MN 62 01 Operationalguidance 2010 Eng Emonc Training Manual

Emergency Obsteric and Newborn care
Training Manual
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EMERGENCY OBSTETRIC AND NEWBORN CARE
TRAINING MANUAL 2010
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TABLE OF CONTENTS
LIST OF ABBREVIATIONS
FOREWORD
ACKNOWLEDGEMENT
THE EmONC TRAINING MANUAL
1. INTRODUCTION
2. JUSTIFICATION: THE BOTSWANA SITUATION
3. CONTENT OF THE TRAINING MANUAL
4. ORGANIZATION AND ADMINISTRATION OF THE COURSE.
5. CONTENT OF THE MODULES
5.1. MODULE 1: MANAGING OBSTETRIC HAEMORRHAGE,
ABORTION AND ANAEMIA.
5.1.1. Session 1: Defining and Understanding
different types of Obstetric Haemorrhage (OH).
5.1.2. Session 2: Bleeding during early Pregnancy.
5.1.3. Session 3: Abortion.
5.1.4. Session 4: Antepartum Haemorrhage (APH).
5.1.5. Session 5: Post Partum Haemorrhage (PPH)
5.1.6. Session 6: Anaemia
5.2. MODULE 2: MANAGING PROLONGED, OBSTRUCTED LABOUR AND

PREMATURE LABOUR.
5.2.1. Session 1: Obstructed Labour.
5.2.2. Session 2: Prolonged Labour.
5.2.3. Session 3: Premature Labour
5.3. MODULE 3: MANAGING HYPERTENSIVE DISORDERS IN

PREGNANCY
5.3.1. Session 1: Defining and Classification of Hypertensive Disorders
in Pregnancy
5.3.2. Session 2: Diagnosis Management of Pregnancy
Induced Hypertension
5.3.3. Session 3: Management of Pre-Eclampsia and Severe Pre-Eclampsia
5.3.4. Session 4: Diagnosis and Management of Eclampsia
5.3.5. Session 5: Management of Complications of Pre-Eclampsia
and Eclampsia
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5.4. MODULE 4: MANAGING PUERPERAL SEPSIS.
5.4.1. Session 1: Defining and Classify Sepsis in Obstetric.
5.4.2. Session 2: Causes , Diagnosis and Management of Infections
in Pregnancy
5.4.3. Session 3: Abortal Sepsis
5.4.4. Session 4: Puerperal Sepsis
5.5. MODULE 5: MANAGING OF THE NEWBORN COMPLICATIONS

(INFECTIONS, ASPHYXIA, PREMATURITY).
5.5.1. Session 1: Managing Neonatal Asphyxia
5.5.2. Session 2: Managing Neonatal Infections
5.5.3. Session 3: Managing Premature Baby
5.5.4. Session 4: Managing Neonatal Hypoglycaemia
6. ANNEXES
6.1. SPECIAL PROCEDURES
6.2. REFERANCE MATERIALS

6.2.1. Bimanual compression of the Uterus
6.2.2. Manual removal of the placenta
6.2.3. Vacuum extraction
6.2.4. Repair of episiotomy and perineal tears
6.2.5. Caesarean Section
6.2.6. Neonatal Resuscitation
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ABBREVIATIONS
ANC - Antenatal clinic/care
APH - Ante partum haemorrhage
ARM - Artificial Rupture of Membranes
ARV - Antiretroviral
BBT - Basal Body Temperature
BOH - Bad Obstetric History
BP - Blood pressure
CPD - Cephalo pelvic Disproportion
C/S - Caesarean section
D&C - Dilatation and curettage
DIC - Disseminated Intra vascular coagulopathy
DVT - Deep Venous Thrombosis
ECS - Elective Caesarean Section
EFW - Estimated Foetal Weight
EKC - Emergency Obstetric Care
E/S - Endocervical Swab
ESR - Erythrocyte Sedimentation Rate
EUA - Examination under Anaesthesia
FP - Family Planning
FSB - Fresh Stillbirth
GIT - Gastro Intestinal Tract
HDP - Hypertensive Disorders of Pregnancy
HIV - Human-Immunodeficiency Virus
HVS - High Vaginal Swab
ICT - Indirect Coombs Test
IPH - Intrapartum Haemorrhage
IPT - Isoniazid Tuberculosis Preventative Therapy
IUFD - Intrauterine Foetal Death
IUGR - Intrauterine Growth Restriction
I/V - Intravenous
LFT - Liver Function Tests
MSB - Macerated Stillbirth
NND - Neonatal Death
OH - Obstetric Haemorrhage
PE - Pre-eclampsia
PIH - Pregnancy Induced Hypertension
PNC - Postnatal clinic/care
POC - Products of Conception
POD - Pouch of Dou’glas
PPH - Postpartum Haemorrhage
PRN - As necessary
PROM - Premature Rupture of Membranes
PV - Per Vagina (Per Vaginal)
RDS - Respiratory Distress Syndrome
RH Factor - Rhesus Factor
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RFT - Renal Function Test
SB - Stillbirth
SFD - Small for dates
SMI - Safe Motherhood Initiative
SRHS - Sexual Reproductive Health Services
SROM - Spontaneous Rupture of Membranes
STI - Sexually Transmitted Illness
Temp - Temperature
TB - Tuberculosis
TPHA - Trepanoma Palladium Haemoaglutination Assay
TV - Trichomonas Vaginalis
U/S - Ultra Sound
UNFPA - United Nations Fund For Population Activities
UNICEF - United nations Children’s Fund
UTI - Urinary Tract Infection
VCT - Voluntary Counselling and Testing
VDRL - Venereal Disease Research Laboratory
VE - Vacuum Extraction
WHO - World Health Organization
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FOREWORD
The safe motherhood program was initiated in Botswana in the early nineties with an aim of reducing maternal morbidity
and mortality as well as improving the quality of lives of women. Concerted efforts to improve maternal and child health
through programmes and interventions were put in place and implemented. These include development of Safe Motherhood
manuals as well as capacity building for health workers with an endeavour to improve the provision of quality care. It has
however, been noted over time that these efforts did not bear much fruits as maternal mortality continued to escalate.
The current data has revealed an increase in maternal mortality trends (despite the good access to health services) from
157/100.000 in 2005 to 198 maternal deaths per 100,000 live births in 2008 with main causes of maternal mortality being;
hemorrhage (28%), pregnancy - induced hypertension (16%), abortion (13%), AIDS (14%), and sepsis (12%). On the other hand,
newborn mortality is also a major cause for concern as it is estimated at 34 deaths per 1000, with the main causes being asph yxia,
prematurity and infections. This is estimated to contribute 40% of all deaths of children under – five years old.
It is worth noting that 75% of all maternal deaths are preventable if quality services are availed to women during
pregnancy, childbirth and post partum period. If Botswana is to be among countries geared towards achieving MDG 4 & 5
by 2015, then there is need to double the efforts in provision of quality care in the health facilities to accelerate progress
towards reduction of maternal and newborn morbidity and mortality.
It is in this regard that Botswana Government through the Ministry of Health has committed itself to the development of a
comprehensive training manual on Emergency Obstetric and Newborn Care (EmONC) which will be used for in – service
training of health workers working in maternity settings to improve clinical performance.
The purpose of this training manual is to ensure that health workers have the skills and knowledge to provide appropriate
care at the most vulnerable period of the mother and the newborn’s life. It is also intended to provide guidelines for improv-
ing quality of emergency obstetric care to both the mother and the newborn, ensures neonatal care is timely and efficiently
provided and identifies knowledge/skill gaps of practitioners and takes appropriate remedial action.
The modules developed in this Training Manual are primarily intended for in-service training but can also be used in basic
training and skills update of other health care professionals (nurses, midwives and doctors). The modules aim to help
skilled practitioners to think critically and make effective decisions on the basis of solid knowledge and understanding of
obstetric complications.
To respond to the need of the country in dealing with the main causes of maternal and newborn morbidity and mortality,
the training manual is divided into 5 Modules:
• Managing Obstetric Haemorrhage, Abortion and Anaemia
• Managing Prolonged, Obstructed Labour and Premature Labour
• Managing Hypertension Disorders in Pregnancy;
• Managing Puerperal Infections
• Managing Neonatal Complications.
It is hoped that this training will contribute to the improvement of quality of services to women during pregnancy, labour,
delivery and post-natal period.
Dr K. Seipone
Director of Health Services
Ministry of Health
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ACKNOWLEDGEMENT
This manual is the first comprehensive training guide prepared by Ministry of Health. The training guide was developed using the
already available Basic standard and using evidence based reference from WHO latest reviewed documents. It is aimed to provide
standard in-service training for doctors, midwives and nurses to improve their skill and knowledge in management of obstetric
care including newborn. The process of development was made possible through the sponsorship of the Botswana Ministry of
Health, WHO and UNFPA. We wish to thank the management of various health facilities for their cooperation in allowing their
staff members to participate throughout the process of review. Special appreciation goes to
WHO through the leadership of Dr E. Nyarko by engaging the consultant Dr Antoine Serufilira who worked with task force
members to develop the training guide.
The training guide has been developed to address the practical issue in obstetric care in Botswana. The reproductive health
problems prevalent in Botswana are not principally different from those encountered elsewhere in the Africa region. How-
ever, the practical approach in the management of these problems requires improved quality of care to reduce morbidity
and mortality associated with childbirth. It is in this regard that the experience of local health providers was extensively
utilized in the development of the training guide.
The development of the training manual was made possible by tireless work of the task force, namely: Dr. Theu J , Ms
Bolele B, Ms Keipedile L, Ms Makhala R, Dr Petr S, Ms Moatshe B, Dr. Horombe , Ms Legopelo C, Ms Lephirimile E, Ms Thipe
B,Ms Masweu M, Mr Keakabetse T.R, Ms Oagile L ,Ms Matlhare K, Ms Sello W, Ms Maribe L.S, Ms Basinoko T, Mr
Thapelo G, Ms Mpofu K, Ms Osenotse K, Ms Odiseng O, Ms Masuku A, Ms Motseotsile G.B. The team developed the
training guide applying their wide experience on maternal and newborn care, as well as literature search. The training guide
approach is more practical hence user friendly for maternity care settings country wide.
The work could have not being completed without the support of Ms V M Leburu, Manager Sexual Reproductive Health Di-
vision. We thank Ms Ontiretse Moeng, Typist under Department of Public Health, for compilation of the document. We thank all
those we consulted to give guidance although they were not able to be present we say your response was quite valuable.
Thank you
S. El-Halabi
Director
Department of Public Health
Ministry of Health
Botswana
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EMERGENCY OBSTETRIC AND NEWBORN CARE TRAINING MANUAL
1. INTRODUCTION
Every year, more than 529 000 women and more than 5.7 million babies die before, during, or after
childbirth, the majority in developing countries. The main causes of maternal morbidity and mortality
are complications arising from hemorrhage, unsafe abortion, eclampsia, sepsis and obstructed labour.
An unacceptable number of babies around the world die in the first month of life with the highest
number dying within the first 24 hours of birth. Many of these deaths occur to babies born too early
and too small, or with infections, or to babies asphyxiated around the time of delivery. Studies have
shown that many newborn lives can be saved by the use of simple low technological interventions.
Reducing maternal and newborn mortality has arrived at the top of health and development agendas.
To achieve the Millennium Development Goals of a 75% reduction in the maternal mortality and the
2/3 reduction in the under-five infants mortality between 1990 and 2015, countries throughout the
world are investing more energy and resources into providing equitable, adequate maternal and
newborn health services.
While most pregnancies and births are uneventful, all pregnancies are at risk. Around 15% of all
pregnant women develop a potentially life-threatening complication that calls for skilled care and
some will require a major obstetrical intervention to survive. One of the best ways of reducing
maternal and newborn mortality is by improving the availability, accessibility, quality and use of
services for the treatment of complications that arise during pregnancy, childbirth and postpartum.
These services are collectively known as Emergency Obstetric and Newborn Care (EmONC).
Major causes of maternal mortality that is haemorrhage, sepsis, unsafe abortion, hypertensive disorders
and obstructed labour can be treated at an appropriate health facility, well-staffed, well-equipped
health services as well as easy and prompt referral between and within facilities. In such settings, many
newborns who might otherwise die can also be saved.
Setting standards for emergency obstetric and newborn care

- Basic emergency obstetric and newborn care, provided in health centres, clinics with or without beds,
includes the capabilities for the following 7 Signal Functions:
a) Signal Functions of Basic EmOC
1. Manual Removal of the Placenta
2. Removal of retained products of conception (MVA)
3. Assisted vaginal Delivery ( Forceps, Vacuum extraction)
4. Repair of Episiotomy and Perineal tears
5. Paranteral Antibiotics
6. Paranteral Oxytocics
7. Paranteral Anti-convulsants and anti –hypertensives
8. Resuscitation of a newborn
b) Signal Functions of Comprehensive EmONC

1. Manual Removal of the Placenta.
2. Removal of retained placenta Products (MVA).
3. Assisted vaginal Delivery ( Forceps, Vacuum extraction).
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4. Repair of Episiotomy and Perineal tears.
5. Paranteral Antibiotics.
6. Paranteral Oxytocics.
7. Paranteral Anti-convulsants and anti –hypertensives.
8. Resuscitation of a newborn
Plus
9. Caesarean Section.
10. Blood Transfusion.
Guidelines jointly issued in 1997 by WHO, UNICEF, and UNFPA, recommended that for every
500,000 people there should be four facilities offering basic and one facility offering comprehensive
essential obstetric care. To manage obstetric complications, a facility must have at least two skilled
attendants covering 24 hours a day and seven days a week, assisted by trained support staff. To
manage complications requiring surgery, the facilities must have a functional operating theatre, more
support staff and must be able to administer blood transfusions and anaesthesia. Existing facilities
(district hospitals and health centres) can often, with just a few changes, be upgraded to provide
emergency obstetric and newborn care.
2. JUSTICICATION: THE BOTSWANA SITUATION

Despite high skilled attendance (94%) and high utilization of ANC (95%) services Maternal Mortality
Ratio has increased from 157/100,000 in 2005 to 198/100,000 live births in 2008. This situation is really
disturbing considering that the country as others is on the countdown to 2015, where the MMR should be
81 deaths per 100,000 live births. The main causes of maternal mortality in Botswana are: Haemorrhage
(28%), Pregnancy Induced Hypertension (16%), Abortion (13%), AIDS (14), and Sepsis (12%). Direct
causes of maternal mortality claim 75% of all maternal deaths. These direct causes are avoidable if quality
services are availed to women during pregnancy, childbirth and post partum period.
Newborn mortality is estimated at 34 deaths per 1000 live births, and the main causes are: Asphyxia,
Prematurity and Infections.
Contrary to what is occurring in the majority of other African countries, Botswana is recording good
figures in terms of pregnant women attending ANC services and skilled attendant at birth, meaning
that the majority of maternal deaths are occurring in health facilities. Indicating a problem of quality of
services offered at health facility level and efforts have to be made in dealing the Third Delay. The
main contributors factors of this situation are poor quality of services offered (missed diagnosis,
mismanagement, poor monitoring, inadequate equipment, etc).
One of the strategies prioritized by the Government of Botswana is to pay attention to the third delay
in strengthening the capacity of all health workers in management of obstetric emergencies.
The Ministry of Health has identified a critical demand to ongoing in-country training for Emergency
Obstetric and Newborn Care providers and thus the development of this manual with the support of
WHO.
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3. CONTENT OF THE EmONC TRAINING MANUAL
The Emergency Obstetric and Newborn Care Course aims to ensure that health workers have the skills
and knowledge to provide appropriate care at the most vulnerable period of the mother and
the newborn’s life.
3.1. The purpose of this manual:

- To provide knowledge and skills that will contribute to the reduction of maternal and newborn
morbidity and mortality.
- To provide guidelines for improving safety and quality of obstetric care to pregnant women at
Clinics with and without maternity beds.
- To ensure neonatal care is timely and efficiently provided.
- To identify knowledge/skill gaps of practitioners and take appropriate remedial action.
The modules developed in this Training Manual are primarily intended for in-service training but can
also be used in basic training and skills update of other health care professionals (nurses and doctors).
The modules aim to help skilled practitioners to think critically and make effective decisions on the
basis of solid knowledge and understanding of these complications.
3.2. Content of the Training Manual

To respond to the need of the country in dealing with the main causes of Maternal mortality and
newborn mortality and morbidity, the training manual is divided into 5 Modules:
1. Managing Obstetric Haemorrhage, Abortion and Anaemia
2. Managing Prolonged, Obstructed Labour and Premature Labour
3. Managing Hypertension Disorders in Pregnancy;
4. Managing Puerperal Infections
5. Managing Neonatal Complications.
3.3. Structure of the Modules

Each module includes the following:
1. Introduction
2. Summary of the Module listing the titles of various sessions, teaching-learning methods, resources
to be used, and time frame for each session
3. Details for each session
4. Instructions for the facilitator
5. Instructions for participants
Module 1: Managing Obstetric Haemorrhage, Abortion and Anaemia

Teaching sessions include definitions, diagnosis and management of the main causes of haemorrhage
in early and late pregnancy, intrapartum and postpartum. Skills covered include identification of risk
factors, massaging the uterus, applying bimanual compression to the uterus, suturing of perineal tears
and manual removal of the placenta.
Sessions also cover factors related to abortion and discuss the role of nurses, midwives and doctors in
abortion care, with particular emphasis on emergency abortion care. Skills include: manual vacuum
aspiration and post-abortion family planning counselling and methods. Teaching session will also include
definition, diagnosis and management of anaemia during pregnancy, intrapartum, and postpartum.
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Module 2: Managing Prolonged, Obstructed Labour and Premature Labour
Teaching sessions explain risk factors and offer guidance on how to use the partograph in monitoring
prolonged labour and how to identify the signs of obstructed labour. Skills covered include: assessing
pelvic capacity, diagnosing presentation and position of the baby, assessing descent of the foetal head,
recognizing obstructed labour and performing vacuum extraction. The teaching session will also
include definition, risk factors predisposing to premature labour and management of premature labour.
Module 3: Managing Hypertensive Disorders in Pregnancy

Sessions include information about hypertension, the stages of an eclamptic fit, risk factors, prevention
and management. Skills covered include: differential diagnosis, taking of blood samples, intravenous
infusion, administering of drugs, insertion of a urinary catheter, and care and observation during an
eclamptic fit.
Module 4: Managing Puerperal Sepsis

An explanation of puerperal sepsis is followed by sessions dealing with underlying risk factors,
identification and differentiation from other conditions, prevention and management. Skills covered
include: taking a midstream specimen of urine, taking a high vaginal swab and maintaining vulval
hygiene.
Module 5: Managing of the Newborn Complications (Infections, Asphyxia, Prematurity).

Module emphasise on early detection of signs and management of the main complications that kill the
newborn: Infections, Asphyxia, and Premature baby or small babies. Clinical skill includes essential
care for the newborn and the resuscitation of the Newborn. Primary prevention through emergency
obstetric care is the most cost-effective solution.
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4. ORGANISATION AND ADMINISTRATION OF THE EmONC COURSE
4.1. Length of the course
The course duration is approximately 2 weeks, that is, 5 days of theoretical course and 5 days in
hospital based clinical demonstration, observation and practice.
4.2. Order of the sessions

This course is arranged in modules to give it flexibility. Each module contains a number of session
units which are arranged in a logical order for teaching. Each module can be taught alone,
according to the need of a health facility, or be taught together with other modules as a
comprehensive course on EmONC.
4.3. Organization of the individual sessions

Each session contains the following parts:
1. Introduction (session outline/plan and timeframe)
2. Aim
3. Learning Objectives
4. The content of the session
4.4. Teaching methods

The course uses a variety of teaching methods, which
include: 1 Lecture presentations,
2 Demonstrations,
3 Group work and Discussion,
4 Role-play,
5 Clinical observation and practice,
6 Case study exercises.
It is advisable to vary the methods used during a teaching day to keep the attention of the participants.
Each session includes full teaching instructions.
4.5. Clinical practice information

The clinical practices is a vital part of this course, they are designed to give participants the
opportunity to observe and practice skills seen and learned earlier in the classroom with mothers and
babies in the delivery room, ward areas, special care unit and clinics.
The clinical practice should take place at a convenient time for the health facility, and in facilities
where the participant is most likely to meet the full objectives of the individual practices (see the
objectives on the first page of each clinic practice information and task sheets after the sessions in each
module: to discuss with the consultant).
Clinical practices need to be organized well in advance of the course and the clinical session. This
ensures that appropriate mothers and babies can be selected for participants to visit or to coincide with
care activity. Clinical practice group work is restricted to four participants, though many of the clinical
practice activities are suitable for participants working in pairs or individually supervised by one
trainer or clinical facilitator.
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4.6. Evaluating and monitoring the course
• The course is evaluated by participants using:
An evaluation questionnaire, which can, either be completed at the end of each study day or at the end
of the course. This formative evaluation is particularly useful if filled in daily because it gives the
trainers and clinical facilitators the opportunity to discuss issues raised and make any necessary
changes. This evaluation sheet should be kept as simple as possible.
The participants are evaluated at the end of the training by filling a post-test questionnaire.
• The clinical practice checklists provide information on participant’s practical skills and ability to use
them appropriately.
N.B. The content of each session was adapted from the: (Guidelines for Antenatal Care and the
Management of Emergency Obstetric Care and PMTCT), a tool developed by the Ministry of Health
which has been reviewed and updated and should be used concurrently. The times new roman new roman
suggested for session length and individual parts of each session are approximate and can be varied to suit
the needs of the trainers or the participants, for example if extra time is needed for discussion.
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5.1. MODULE 1: MANAGING OBSTETRIC HAEMORRHAGE, ABORTION AND ANAEMIA
This module is to enable participants to understand that obstetric haemorrhage constitutes an
obstetrical emergency requiring immediate and appropriate care and treatment. It is quite often
unforeseeable and constitutes the first cause of maternal death.
SUMMARY OF THE MODULE

SESSION TEACHING - LEARNING TIME FRAME Total: 8 h
METHODS
1. Defining and Understand- Modified Lecture, Discussion, 30 min
ing different types of Obstetric
Haemorrhage (OH)
2. Bleeding in early pregnancy Modified Lecture, Group Work, 90 min
Discussion
3. Abortions Modified Lecture, Case Study, 1 hrs
Discussion
4. Anti-partum Haemorrhage. Modified Lecture, Group Work, 90 min
Discussion
5. PPH Modified Lecture, Role Play, 2h
Discussion
6. Complications and prevention Modified Lecture, Discussion 30 min
of OH
7. Anaemia Modified Lecture, Case Study, 1 hour
Discussion
5.1.1. SESSION 1: DEFINING AND UNDERSTANDING DIFFERENT TYPES OF

OBSTETRIC HAEMORRHAGE (OH)
5.1.1.1 Session outline: 30 min

• Introduce session: Aim of the session……………..……………………….…5 min
• Definition and types of OH during pregnancy, childbirth

and postpartum....…......................................................................................20 min
• Conclusion…………………………………………….….……………..…….5 min
5.1.1.2. Aim
The aim of this session is to enable participants to define and describe the various types of
obstetric haemorrhage (OH).
5.1.1.3. Learning Objectives

By the end of this session, the learners will be able to:
• Define obstetric haemorrhage;
• To describe various types of OH during pregnancy, childbirth and postpartum.
5.1.1.4. Content of Session 1
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A) Definition: Obstetric haemorrhage (OH) is defined as bleeding related to
pregnancy and childbirth.
Obstetrics haemorrhage can be broadly divided into the following:

i) Bleeding in early pregnancy
ii) Bleeding in late pregnancy
iii) Postpartum haemorrhage:
B) Causes and predisposing factors of obstetric haemorrhage
Causes:
i). Bleeding in early pregnancy:
• Abortion,
• Ectopic pregnancy
• Molar pregnancy.
ii). Bleeding in late pregnancy

iii) Antepartum haemorrhage (APH): Bleeding before the onset of labour
after 24 weeks of gestation .
APH is classified according to the causes:
• Placenta praevia
• Abruptio placentae
• Incidental:
• Uterine cervical lesions (e.g. cervical erosion, polyps and cancer)
• Genital infections (e.g. genital warts)
• Vaginal varicosities
• Vasa – praevia: This is whereby foetal vessels go through membranes and
present at the cervical os.
iv) Intrapartum Haemorrhage: Bleeding that occurs during labour

Causes of intrapartum haemorrhage include:
• Ruptured uterus,
• Separation of the placenta following rupture of membranes
• Rupture of vaginal varicose veins
• Abruptio placentae
• Placenta praevia
v). Postpartum Haemorrhage (PPH): Bleeding that occurs after the delivery of the baby and
includes bleeding prior to and after delivery of the placenta. The current widely used definition of
postpartum haemorrhage considers the loss of blood in excess of 500ml after vaginal delivery &
1000ml for C/S.
C) Predisposing factors:
Predisposing factors to bleeding in pregnancy may be pre-existing or inherent to pregnancy itself
or those created by poor and inappropriate management of pregnancy, labour and delivery.
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i) Pre-existing or pregnancy inherent factors:
• Blood coagulopathies: Thrombocytopenia, pancytopaenia, drug-induced coagulopathy.
• Previous history of PPH
• Previous caesarean section
• Multiparity
• Multiple pregnancy
• Large Babies
• Polyhydramnios
• Uncontrollable Pre-eclampsia or eclampsia: which may cause blood coagulopaty.
• Precipitate labour
• Uterine tumours like fibroids: frequently the contraction and involution of the
uterus is interfered with.
ii) Factors due to inefficient management of pregnancy, labour and delivery:

• Anaemia in pregnancy
• Obstructed labour
• Prolonged labour
• Injudicious use of oxytocin: for induction or augmentation of labour which may result in rupture of
the uterus, precipitate labour, or abruptio placentae.
• Dysfunctional labour: this may cause prolonged labour and PPH.
• Uncontrolled drainage of amniotic fluid during ARM in cases of polyhydramnios. This may lead to
abrupt contraction of the uterus with the resultant premature separation of the placenta.
• Severe PE or Eclampsia: which may predispose to coagulopaty.
• Inadequate monitoring of patients with previous caesarean section scar in labour
• Traumatic instrumental vaginal delivery
iii) Other factors:

• Trauma on the gravid uterus.
• This may result from physical assault and includes application of fundal pressure in the second
stage of labour.
• Excessive physical exertion and vigorous exercises.
• Undetermined factors.
5.1.2. SESSION 2: BLEEDING DURING EARLY PREGNANCY

The main causes of bleeding in early pregnancy are ectopic pregnancy and abortion.
A. ECTOPIC PREGNANCY
5.1.2.1. Aim
The aim of this session is to explain how to diagnose and manage the main causes of
ectopic pregnancy.
5.1.2.2. Session outline: 90 min

• Introduce session: Aim of the session…………………..……………….……...5 min
• Signs and symptoms of ectopic pregnancy….…..……………….…….………15 min
• Differential diagnosis of ectopic pregnancy................. ………………….…...15 min
• Management of ectopic pregnancy .....………………………………………...40 min
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• Complications of ectopic pregnancy …......……………………………………15 min

By the end of this session, learners will be able to:
• Describe signs and symptoms of ectopic pregnancy;
• Describe how to manage ectopic pregnancy .
• Describe the main complications of ectopic pregnancy.

A. Definition:
Ectopic pregnancy (extra uterine pregnancy, heterotopic pregnancy) refers to a pregnancy in
which implantation occurs outside the uterine cavity.
B. Classification: be classified according to localisation or clinical presentation
i) Classification according to the localisation

• Tubal (interstitial, isthmic, ampullary, fimbrial):
The implantation occurs in the various parts of the tube, the commonest being the ampullary
area. Tubal pregnancy constitutes about 99% of all extra uterine pregnancies.
• Ovarian: In this form of ectopic pregnancy the fertilization and implantation occur at the ovulation
site in the ovary adjoining the fimbrial end of the tube. It is commonly tubo-ovarian which eventu-
ally develops into abdominal - ovarian. This constitutes about 0.5% of extra uterine pregnancies.
• Abdominal: Often is secondary to tubal, ovarian or tubo-ovarian.
• Rare forms: Cervical and ectopic combined with intrauterine pregnancy.
ii) Extra uterine pregnancy can present clinically as;

• Ruptured ectopic pregnancy. This causes severe intraperitoneal bleeding.
• Unruptured ectopic pregnancy.
• “Slow leaking” or chronic ectopic pregnancy. The point of rupture generally is small and the
bleeding is not acute causing vague and inaccurate symptoms and signs.
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C. Clinical Presentation of Ectopic pregnancy
Symptoms Signs
Pain: Adnexal tenderness:
Lower abdominal pain sometimes new roman This may be elicited by abdominal palpation or
new roman unilateral occurs in almost all cases bimanual examination
Bleeding: Adnexal mass:

Abnormal uterine bleeding (usually irregular, Unilateral tender adnexal mass in the presence of
scanty and dark) occurs in nearly 3/4 of cases. amenorrhoea is a strong indicator
Amenorrhoea: Uterine size:

Patients often present with history of having Changes in the uterus including the size are
missed periods for several weeks. not correlative to duration of amenorrhoea and
pregnancy
Dizziness and Fainting: Cervical Excitation:

Syncope often of sudden onset may occur. This This is generally strongly positive.
is more frequent in cases of ruptured ectopic
pregnancy Phreinic nerve syndrome – shoulder
pains related to irritation of the diaphragm.
D. Diagnosis
Clinical Special Exam
Proper History: Paracentesis:
-Attention to menstrual history and onset of Non-clotting blood- often proves negative.
symptoms Culdocentesis:
-Risk factors (see causes of extra uterine More accurate than paracentesis should be
pregnancy) preferred.
Examination: Ultrasound:
General physical with special reference to Not very dependable since it relies on
pallor and abdominal tenderness, guarding and demonstrating a uterine cavity empty of POC and
shifting dullness. an adnexal mass.
Vital Signs. Laparoscopy:
• Blood pressure may be low, Most accurate special examination
• pulse may be rapid and thread and a degree of
fever may be present. Laboratory:
NB: Normal findings however, do not exclude • Pregnancy test
ectopic pregnancy. • Full haemogram
• Group and X-match blood
Gynaecological:
Speculum examination
Digital examination to assess uterus, adnexae
and POD for abnormal mass and tenderness
20
E. Management
When a patient presents with what appears to be extra uterine pregnancy, the way to proceed is as
fol-lows (flow chart No.1.)
Flow Chart No. 1

MANAGMENT OF ECTOPIC PREGNANCY
. Take general and

specific history
. Perform general physical
and gynaecological
examination
Make a clinical
diagnosis
Ruptured Unruptured
Confirm through paracentesis

culdocentesis (if available)
Full haemogram
Full haemogram Urinalysis
Group X-match blood Group and X-match blood
Special examination:
ultrasound or
Emergency Laparotomy laparoscopy
Do not wait for
availablity of blood
Confirmed diagnosis
Laparotomy/Operative
laparoscopy
21
F. Complications of Extra uterine Pregnancy:
1. Haemorrhagic anaemia.
2. Hypovolemic shock in acute rupture.
3. Peritonitis if laparotomy is delayed.
4. Salpingitis particularly in chronic tubal pregnancy.
5. Infertility following surgical treatment of the ectopic pregnancy and or chronic salpingitis.
6. Recurrent ectopic pregnancy
7. Maternal mortality
5.1.3. SESSION 3: ABORTION

A). ABORTION
5.1.3.1. Aim
The aim of this session is to explain how to recognise various types of Abortion and how to
manage Abortion.

• Introduce session: Aim of the session…………………..……………….……… 5 min
• Definition of abortion………………………………………………………….. 5 min
• Causes of spontaneous abortion………..….….…………………….…………. 5 min
• Clinical classification and management of spontaneous abortion…………….. 5 min
• Management of septic abortion……………………………………………….. 15 min
• Management of missed abortion…………………………………………….… 15 min
• Prevention of abortion and its complications…………………………………. 10 min

By the end of this session, learners will be able to:
• Describe signs and symptoms of abortion
• Outline clinical classification and management of spontaneous abortion
• Describe how to recognise and manage septic abortion and missed abortion
• Describe the main complications of abortion.
• Describe the prevention of abortion and its complications.
22
Definition:
Abortion is the termination of pregnancy before 24 weeks of gestation or expulsion of a non-
viable foetus weighing 500 grams or less.
Types Definition
Spontaneous Abortion: This is abortion occurring without deliberate external intervention.
Missed Abortion: The retention in utero of POC after foetal death before 24 weeks
of gestation
Incomplete Abortion: The partial expulsion of the product of conception before viability
stage.
Complete Abortion: The expulsion of all the products of conception before viability
stage.
Inevitable Abortion: This is the state in which there is uterine contraction with progres-
sive effacement and dilatation of the uterine cervix with or without
uterine bleeding before the stage of foetal viability.
Septic Abortion Abortion associated with localised /generalised infection.
Habitual Abortion This is defined as three consecutive spontaneous abortion.
Induced Abortion Deliberate termination of pregnancy before the stage of viability.

It can either be legal or illegal
Early/late Abortion Occurs before 16 weeks while late abortion occurs after 16 weeks
of gestation.
DIAGNOSIS OF ABORTION
Think of an abortion in the face of:
• Amenorrhea
• Intermittent rhythmic abdomino-pelvic pains
• Vaginal bleeding
• Partial expulsion of POC
• Dilated cervix
• Smaller uterus than expected for the gestation
Spontaneous abortion
Causes of spontaneous abortion
i. Foetal Factors:
First Trimester: • Abnormality of chromosomal structure
• Blighted ovum
• Poor implantation and inefficient placental development
Second Trimester: • Congenital infections e.g. syphilis

• Erythroblastosis
23
ii Maternal Factors:
Systemic Diseases: • Infections eg. malaria, chlamydia, herpes simplex, HIV & AIDS.
• Endocrine disorders e.g. diabetes mellitus, hyperthyroidism.
• Hypertension
• Malnutrition
Uterine Abnormalities
and Defects • Uterine fibroids
• Cervical incompetence
• Congenital abnormalities of the uterus
• Repeated or over curettage and other uterine scarring
Trauma • Physical trauma on the gravid uterus
Other disorders • Psychological and emotional disorder

• Immunological disorders.
• Unfavourable habits e.g. alcoholism, smoking, drug abuse.
Clinical classification and management of abortion
STAGE OF ABORTION CLINICAL PRESENTATION MANAGEMENT

. mild lower abdominal pains and Counselling, rest, avoid strenuous
backache activities.
. slight PV bleeding Investigate and treat the cause.
1. Threatened abortion . cervix is not effaced
. cervical os is closed
. uterus is enlarged
. painful cramps or contractions -Facilitate abortion by evacuation
. uterine bleeding of the uterus if pregnancy is <12
. cervical effacement and dilatation weeks,
2. Inevitable Abortion . membranes may be ruptured. - by oxcytocin drip or
prostaglandins for spontaneous
expulsion if pregnancy is >12/40
. abdominal cramps may or may not be . treat as emergency

present . i/v line with or without a drip
. cervical os is generally open depending on amount of blood loss.
. varying degrees of PV bleeding . emergency evacuation of the
. uterine size will be considerably less uterus
3. Incomplete Abortion
than gestational age. . provide broad spectrum antibiotic
prophylaxis if necessary and give
analgesics
24
STAGE OF ABORTION CLINICAL PRESENTATION MANAGEMENT
. abdominal pain or cramps have .give broad spectrum antibiotic if
subsided necessary.
. no active uterine bleeding . provide haematinics if necessary
. cervical os is generally closed
4. Complete Abortion
. uterine size is considerably less than
the gestational age or is almost normal
size
. pelvic pain of varying degrees . iv line for rehydration

. offensive blood stained or brownish . endocervical swab, HVS and
vaginal discharge blood for culture and sensitivity
. varying degrees of fever test.
. pelvic tenderness . start on broad spectrum iv
. there may be fluid (pus) collection antibacterial cover as soon as
in the POD. possible, do evacuation
5. Septic Abortion . cervical canal is generally open . if there is peritonitis, may
. POC may be felt through the require laparotomy for drainage
cervical canal . transfuse blood if anaemia is
. commonly the patient is anaemic severe
. give haematinics if anaemia is
mild or moderate.
. signs and symptoms of . coagulation screen: clotting

pregnancy disappear with time time, prothrombin time index
. uterine size progressively -if uterus is >12 weeks
decreases ripen cervix with
. pregnancy test maybe negative prostaglandins gel,
- Presence or absence of then induce labour with
brownish vaginal extramniotic prostaglandins
or oxytocin drip
-if uterus is <12 weeks,
evacuate the uterus in theatre
6. Missed Abortion with an iv line in place and
blood available
. x-match blood
. evacuate the uterus in
theatre under general
anaesthesia.
-physical and pelvic
examination
-ultrasonography
25
Flow Chart N0.2
D) GUIDELINE FOR THE MANAGEMENT OF SEPTIC ABORTION
Through history and physical examination

(look for genital laceration and fever)
Admit and investigate
If in shock: Maintain input/output If not in shock: Do lab test: FBC,

chart. Endocervical swab,
Do lab test: blood culture, RFT, LFT, X-match blood
Endocervical swab, FBC, X- Match
blood.
In all cases, Institute Management immediately, iv antibiotics, analgesics.
If gestation > 12 weeks If gestation <12 weeks, evacuate

Start oxytocin/prostaglandins as soon as possible.
immediately if fetus in utero.
26
NOTE:
The treatment of choice in septic abortions is triple antibiotic therapy
Metronidazole, Ampicillin and Gentamycin intravenously.
Other Antibiotics
• Cefotaxime
• Clindamycin
• Suprapen
E. Complications of abortion:
1. Short Term • Haemorrhage

• Uterine perforation
• Sepsis
• Injury to other organs e.g. genital tract, intestines, bladder
• Shock
• Emotional trauma
• DIC (Disseminated intravascular coagulopathy)
• Maternal death
2. Long Term• Infertility due to tubal blockage resulting from sepsis

• Asherman’s syndrome.
• Psychological and emotional disorder as a result of poor or absence of post
abortion and or pre-abortion counselling. Often women seek abortion services
on emotional bases and post abortion regrets are common. Social reprimands
may also result in this.
• Serious complications leading to prolonged treatment may cause loss
of opportunities like education and jobs.
F. Prevention of abortion and its complications
1. Abortion:
• competent management of gynaecological disorders
• proper nutrition
• liberal regulation of abortion on health grounds to avoid unsafe abortions
• appropriate management of maternal medical disorders
• institutionalised adolescent reproductive health care.
2. Prevention of Complications of Abortion:

• emergency and appropriate management of all types of abortion
• efficient post abortion care and counselling.
• reproductive health education
• adequate training of health personnel
• availability of appropriate facilities and equipment
• availability of blood
For further information, see comprehensive post abortion care manual
27
G. Special notes on abortion:
1. Give prophylactic antibiotics to all clients with abortion.
2. All patients with Rhesus Negative Blood Groups will benefit from anti-
D treatment within 72hours post abortion .
3. All patients evacuated after abortion should be reviewed after one week. Signs
and symptoms of complications should be noted and appropriately managed.
4. Post Abortion Counselling should be done before discharge. It is crucial to include FP

& HIV/AIDS in the short and long term management of patients who have been treated
for abortion
5.1.4. Session 4: ANTEPARTUM HAEMORRHAGE (APH)

5.1.4.1. Aim
The aim of this session is to explain how to diagnose and manage the main causes of Ante
partum Haemorrhage.
5.1.4.2. Session outline:

• Introduce session: Aim of the session…………………..……………………..…5 min
• Causes of APH and their clinical presentation .……………………………..25 min
• Management of APH…………………………………………………………....60 min

• Describe Causes of APH and their clinical presentation
• Describe how to manage APH.

CAUSES OF APH AND THEIR CLINICAL PRESENTATION
Placenta Praevia Abruptio Placenta Incidental Bleeding
History of spotting in the first Varying severity of abdominal Abnormal vaginal discharge
and second trimester and back pain often offensive
Painless bleeding usually in the Irritable, tender uterus, often Intermittent spotting or bleeding
third trimester hypertonic
Usually blood is bright in colour Haemorrhage may be overt or Often bleeding follows physical
concealed contact usually coitus
Abdomen soft If placental separation is not Bleeding spots can be visualised

marginal blood is usually dark using the speculum
in colour
28
Flow chart N0. 3
MANAGEMENT OF APH
Take quick history
Review available documentation
Carry out general examination
Admit patient
Placenta Praevia Do counselling & take consent Make provisional diagnosis

Abruptio Placenta
be fixed
to
Chart
29
5.1.5. Session 5: POST PARTUM HAEMORRHAGE (PPH)
5.1.5.1. Aim
The aim of this session is to explain how to diagnose and manage the main causes of Post
partum Haemorrhage (PPH).

1. Introduce session: Aim of the session…………………………….…………… 10 min
2. Types and causes of PPH.......................................................................................20 min
3. Management of PPH ………………………………………………………..……60 min

1. Describe types and causes of PPH
2. Describe signs and Symptoms of
PPH; 3.Describe how to manage PPH.

i) Causes of primary postpartum haemorrhage:
• Uterine atony
• Lacerations of the birth canal
• Retained POC
• Coagulation defects
• Uterine inversion
ii) Causes of secondary PPH:

• Retained POC
• Insufficient uterine involution
• Puerperal Sepsis
• Surgical wound dehiscence
• Blood coagulopathy
• Shedding of dead tissues following obstructed labour
iii) MANAGEMENT
NB: PPH is an emergency which involve other departments like theatre, blood bank,
transport, switch board, etc. If not managed in 2hrs patient can lose life.
• SHOUT FOR HELP!!!!!!!!!!!!!!!!!!!!!!!!!

• Do not leave the patient alone.
• Involve others from a cleaner up to the doctor.
30
RESUSCITATION;
• Insert 2 large bore IV cannula
• Replace volume R/L or Blood
• Monitor vital signs BP, PR, RR, TEMP and urine output (catheterize the patient)
• Administer oxygen PRN
• Take bloods for FBC, x-match, UE, LFT, coagulation profile.
• Bring PPH pack with the following:
• I.V fluids 2L (N/S or Ringer’s lactate)

• I.V canula two
• Blood giving sets
• Specimen container
• Foley’s catheter
• Pair of gloves
• Drugs (oxytocin, ergometrine)
• Strapping, spirited swabs.
N.B. Identify the cause of PPH and manage accordingly.
MANAGEMENT OF ATONIC UTERUS

An atonic uterus fails to contract after delivery
• continue to massage the uterus
• use oxytocic drugs which can be used together or sequentially, oxytocin 20-40IU in 1000mls
N/S or R/L at 60 drops per min.
• ergometrine or syntomentrine 0.5 mg IM
• anticipate the need for blood early and transfuse when necessary.
If bleeding continues;
Check placenta again for completeness
If there are signs of retained placental fragments, remove remaining placental tissues manually by
forceps or evacuation curettage.
Review the coagulation profile to check for coagulopathies.
If bleeding continues despite above management perform bimanual compression of the

uterus (see annex).
NB: PACKING THE UTERUS IS INEFFECTIVE AND WASTE PRECIOUS TIME

AND IS DANGEROUS.
If bleeding continues use the condom temponade
31
THE USE OF CONDOM TAMPONADE FOR PPH
32
MANAGEMENT OF PPH
be fixed
to
Chart
33
5.1.6. Session 6: COMPLICATIONS AND PREVENTION OF OBSTETRIC HAEMORRHAGE
5.1.6.1. Aim
The aim of this session is to discuss complications and prevention of obstetric haemorrhage
including shock.

• Introduce session: Aim of the session…………..………………………………5 min
• Complications of obstetric haemorrhage……………………………………….10 min
• Prevention of OH………………………………………………………………10 min
• Signs and Symptoms of shock……………………………….………………..10 min
• Assessment and Management of shock…………………………………….….25 min

• Outline complications of OH
• Outline preventive measures of OH
• Define shock
• Describe signs and symptoms of shock;
• Describe how to assess and manage shock.

A) Complications of OH
i) Maternal: • Anaemia
• Shock
• Embolism
• Sepsis
• DIC
• Acute Cardiac failure
• Couvelaire uterus
• Renal cortical and tubular necrosis
• Transfusion infections: hepatitis, HIV, malaria etc.
• Anterior pituitary necrosis (Sheehan’s syndrome).
• Maternal death
ii) Foetal:
• Prematurity
• Severe asphyxia with brain damage
• IUFD
• IUGR
B). Preventive measures of OH:

1. Appropriate legislation and institution of relevant directives designed to eliminate illicitly
induced abortions.
2. Training in skills and technologies of management of abortions.
34
3. Emergency treatment of all types of abortion (see page 22 and 23)
4. Good ANC which focuses on risk identification, counselling of the mothers on the risks, channel-ling
those with risks to appropriate centres for the management and prompt emergency referral.
5. All patients identified to have the risk of OH should be managed in labour with an iv line in situ.
Emergency tray for the treatment of PPH must be prepared in advance. The tray should include:
• oxytocin
• ergometrine or syntometrine
• speculum
• tissue clamps
• iv fluids; ringers lactate and n/saline
• suture materials
• Catheter
This is besides the usual delivery tray.

5. Active management of the third stage must be applied in all deliveries.
NB: Administration of ergometrine is contraindicated in cardiac or HDP patients.
C) SHOCK
Shock is characterized by failure of the circulatory system to maintain adequate perfusion of the vital
organs. Shock is a life threatening condition that requires immediate and intensive management.
ASSESMENT AND MANAGEMENT OF PATIENT IN SHOCK.

Assessment Signs of Shock Management
Increased pulse rate: (110beats per minute or SHOUT FOR HELP!!!
more) - Urgently mobilize all available personnel.
Low blood pressure: (systolic BP less than 90 - Monitor vital signs(BP, PR, RR, Temp)
mm Hg) - If the woman is unconscious turn her to her
side to minimize the risk of aspiration in case she
Increased respiratory rate: (more than 24b/m)
vomits, and ensure that an airway is open.
Scanty urine output: (less than 30 mls/hour) - Keep the woman warm but do not overheat her,
as this will increase peripheral circulation and
Decreased level of consciousness
reduce blood supply to the vital centres.
- Elevate the legs to increase return of blood to
Cold clammy skin the heart (if possible raise the foot end of the
Pallor bed).
Anxiety
35
D) Specific management
• start an IV infusion (two if possible) using a large bore ( 16 gauge or largest available) cannular
or needle.
• collect blood for FBC, X-match and coagulation profile, UE, LFT just before infusion of fluids.
• Rapidly infuse IV fluids N/S or R/L initially at the rate of 1L in 15-20min.
• Give at least 2L of these fluids in first 1 hour. This is over and above fluid replacement
for ongoing losses.
N.B. A more rapid rate of infusion is required in the management of shock from bleeding, aim
at replacing two to three times new roman new roman the estimated loss.
• if peripheral veins cannot be cannulised perform a venous cut down

• continue to monitor vital signs every 15min and blood loss.
• Catheterize the bladder and monitor intake and urine output.
• give oxygen at 6-8 litres per minute by mask or nasal cannulae.
• take steps simultaneously to stop bleeding (e.g. oxytocics, uterine massage,
bimanual compression, aortic compression, preparation for surgical intervention).
• transfuse as soon as possible, to replace blood loss.
• Determine the cause of bleeding and manage accordingly.
• Reassess the woman’s response to fluids within 30minutes to determine if her condition
is improving, signs of improvement include;
• Stabilizing PR (rate of 90 beats per min or less)
• Increasing BP (systolic 100 mmHg or more)
• Improving mental status
• Increasing urine output (30ml per hr or more)
• If the woman’s condition improves;

• adjust IV fluids to 1litre in six hrs
• continue management of underlying cause of bleeding.
E. Special Notes on Obstetric Haemorrhage.

1. All patients presenting with APH should not have digital examination before placenta praevia
has been ruled out with ultrasonography and even after that, the examination should be confined to
cau-tious speculum examination.
2. All patients with APH should be treated as potential cases of placenta abruptio until
otherwise proven.
3. Bleeding in abruptio placentae may be overt or concealed. The severity of the condition should
therefore not be assessed solely on the amount of external bleeding. More serious attention must be
paid to the clinical signs of tenderness, abdominal hypertonicity and foetal distress. Ultrasound exami-
nation is important where it exists. The general condition of the mother should be taken note of. The
patient with abruptio placenta are managed clinically
4. There must be no trial of scar in patients with APH.
36
5. Cumulative nature of the effect of repeated episodes of bleeding in APH dictates that serious
reassessment of the condition and the conservative management be considered with a view to
delivery during recurrent bleeding.
6. In abruptio placentae the risk of DIC developing due to the retroplacental clot is a
serious complication. Do coagulation screening.
7. Anti-D should be given for episodes of APH in RH negative mothers.
5.1.7. SESSION 7: ANAEMIA
5.1.7.1. Session outline : 1 hour

• Introduce session: Aim of the session………………………..………………5 min
• Definition of anaemia ………………………………….……..……………..10 min
• Diagnosis of anaemia…………………………………………………….. …10 min
• Management of anaemia…………………………………………………..…25 min
• Complications of anaemia ………………………………………………..…10 min
5.1.7.2. Aim
The aim of this session is to sensitize participants on the direct causes, signs and symptoms, complica-
tions and management of anemia.
5.1.7.3. . Learning Objectives

On completion of session 1, learners will be able to:
• Define Anaemia
• Outline causes of anaemia
• Describe signs and symptoms of anaemia
• Describe the management of anaemia
• Describe the complications of anaemia
5.1.7.4. Content of the Session 5

A) Definition:
Anaemia in pregnancy is defined by WHO as haemoglobin level of less than 11gm/dl. In Africa, a
haemoglobin level of 10mg/dl is generally considered as the cut off point for anaemia.
B) Causes of anaemia
• Poor diet - nutritional anaemia
• Malaria - Haemolytic anaemia
• Parasitic infestation e.g. hookworm
• Multiparity (short birth intervals)
• Physiological haemodilution in pregnancy
• Haemorrhage: Antepartum or bleeding in early pregnancy
• Geophagia (eating soil)
• HIV infections
37
C) Clinical Signs and Symptoms of Anaemia
i) Symptoms: • general body weakness

• dizziness with episodes of fainting
• palpitations
• breathlessness
ii) Signs: • pallor of the mucus membranes (conjuctiva and the tongue)
• jaundice (on sclera) in haemolytic anaemia of malaria, sickle cell disease
• splenomegally, commonly called “tropical spleen” in chronic malaria.
• koilonychia, in chronic iron deficiency anaemia.
• oedema,
• tachycardia
Assessment:
History taking about nutrition, diet and HIV status
All pregnant mothers with anaemia (i.e. Hb of <10 g/dl) should be subjected to investigations.
Investigations include:
a) Complete haemogram with differential and reticulocyte count.
b) Blood slide for malaria parasites
c) Stool examination for parasitic infestation
d) Urine for analysis, microscopy and culture to exclude chronic renal disease.
e) HIV test
If anaemia persists despite negative results and treatment, the patient must be referred for second
line management at a higher-level facility.
D) MANAGEMENT
NB: Correction of anaemia without establishing the cause gives only a
temporary solution to the problem.
Treatment of anaemia
Stage of Pregnancy Degree of anaemia and treatment
Mild 8-10g/dl Moderate 6-8g/dl Severe less than 6g/dl
Preterm Oral haematinics Oral haematinics Parenteral transfusion
Diet advice Diet advice Diet advice
Term Oral haematinics Oral haematinics Transfusion
Diet advice Diet advice Oral haematinics
Transfusion Diet advice
Intra-partum Transfusion Transfusion
Postpartum Oral haematinics Oral haematinics Transfusion
Diet advice Oral haematinics
Transfusion Diet advice
38
NB
• transfusion depends on patient’s condition
• Withhold initiation of AZT if Hb is less than 7.5g/dl
• Consider change of HAART treatment if Hb drops below 7.5g/dl as per National HIV/AIDS
Guidelines.
Blood transfusion steps

• Open vein with large cannula (size 16g)
• Put up fluids, normal saline / ringers lactate
• Give Furosemide 40mg IV
• Have baseline vital signs
• Fluid balance (oral, IV fluids, urine output)
In addition record;
• Time transfusion started
• Time transfusion completed
• Volume and type of all products transfused
• The unique donation numbers of all products transfused
• Any adverse effects
Monitoring the patient on transfusion

For each unit of blood transfused, monitor the woman at the following stages:
• Before staring the transfusion
• At the onset of the transfusion
• 15 minutes after starting the transfusion
• At least every hour during transfusion
• At four-hour intervals after completing the transfusion
• Monitor; general appearance, temp, pulse, BP and respirations.
E) Complications of anaemia:
Maternal Foetal
Obstetric haemorrhage Foetal malformation
Antenatal infections I.U.G.R.
Abortion IUFD
Cardiac failure (shock) Prematurity
Puerperal sepsis
Maternal death
39
5.2. MODULE 2: MANAGEMENT OF PROLONGED, OBSRUCTED LABOUR
AND PREMATURE LABOUR
This module is to enable participants to understand that obstructed and prolonged labour constitute an
obstetrical emergency requiring immediate and appropriate care and management. Participants will also
understand that premature delivery is associated with higher perinatal morbidity and mortality.
SUMMARY OF THE MODULE: 8 hours
SESSION TEACHING-LEARNING TIME FRAME Total: 8hours

METHODS
1. Obstructed Labour Modified Lecture, Role Play, 2h30

Discussion
2. Prolonged Labour Modified Lecture, Case Study, 2h30

Discussion
3.Premature Labour Modified Lecture, Group Work, 3h

Feedback, Discussion
5.2.1. SESSION 1: OBSTRUCTED LABOUR

5.2.1.1. Session outline: 2h 30 min
• Introduce session: Aim of the session…………………..…………………....…5 min
• Definition of obstructed labour…………………………………….……….....5 min
• Clinical presentation of obstructed labour……………………………….…..40 min
• Complications of obstructed labour……………………………………….....30 min
• Management of obstructed labour…………………………………………...70 min
5.2.1.2. Aim
The aim of this session is to enable participants to be able to recognise the clinical presentations and
describe the management of obstructed labour.

By the end of this session, the participants will be able to:
• define obstructed labour
• outline the various causes of obstructed labour and its clinical presentations,
• outline the main complications of obstructed labour
• describe how to manage obstructed labour
• outline the preventative measures of obstructed labour

A)Definition:
The term “obstructed labour” refers to labour that has failed to progress in the presence of effective
uterine contractions due to mechanical obstruction arising from the birth canal or the foetus or both.
Frequently the cervical dilatation progresses well but corresponding descent of the presenting foetal
40
part does not occur. Obstructed labour is often confused with prolonged labour and vice versa. While
obstructed labour is often prolonged, prolonged labour is often not obstructed and may be caused by
factors other than mechanical.
B) Causes of Obstructed Labour

i) Maternal Causes:
• Contracted pelvis;
• Pelvic tumours e.g. lower uterine segment fibroids, solid ovarian tumours, bladder tumours etc;
• Scarring of pelvic tissues e.g. status post traumaticus, previous surgery on the cervix;
• In-born or acquired pelvic skeletal deformities;
• Dystocia
ii) Foetal Causes:

• Malpresentation
• Malposition
• Macrosomia
• Foetal abnormalities e.g. hydrocephalus, conjoined twins
iii) Feto-maternal causes

- Cephalo pelvic disproportion (CPD)
C) Clinical Presentation:
i) Labour may be prolonged in the presence of effective uterine contractions
ii) Lack of descent of the presenting foetal part with effective uterine contractions.
iii) Arrest of cervical dilatation in the presence of good regular coordinated uterine contractions.
iv) Oedema of the cervix, and in severe cases, vulval oedema.
v) Varying degrees of caput formation and moulding. These may be absent if the presenting
foetal head is not fixed into the pelvic brim.
vi) Maternal exhaustion and dehydration generally manifested with urinary ketones, haemo -
concentration and physical weakness.
vii) Haematuria
viii) Bundle’s ring with ballooning of the lower uterine segment
D) Complications of Obstructed Labour

Maternal complications:
i) Maternal distress
ii) Uterine rupture
iii) Intrapartum and postpartum haemorrhage
iv) Renal failure
v) Sepsis
vi) Fistulae formation (VVF/RVF)
Foetal complications:
i) Foetal distress
ii) Foetal brain damage (mental retardation)
iii) Intra-uterine foetal death
iv) Neonatal sepsis
v) Neonatal death
41
E) MANAGEMENT OF OBSTRUCTED LABOR
OBSTRUCTED LABOR
• Urgent admission, include review

the obstetric records
• Monitor feto-maternal wellbeing every
15min
• Emergency measures
• Oxygen
• iv drip (dextrose/saline)
• complete haemogram
• blood grouping & x-match
• iv antibiotics
• catheterization (bladder)
• Prepare for c/s (if indicated) and
inform theatre on time
foetus alive foetus dead
Emergency Cephalic Malpresentation

Caesarean /section incl. breech
Head <2/5, Head >2/5, caput + moulding

mild/mod with/without
for type of
caput/mouldin
surgical incisions (skin & caput/noulding g
uterine)
vacuum ext/vag.
Destr
delivery
Emergency c/s
42
F) Prevention of Obstructed Labour:
i) Good Antenatal Care which involves:

• proper examination and identification of risk factors at booking.
• adequate monitoring and assessment of:
i) maternal nutrition
ii) baby size and presentation
iii) adequacy of the pelvis
iv) identification of the risk factors likely to predispose to obstructed labour
v) appropriate advice and counselling
ii) Timely referral:

- antenatally
- intrapartum
iii) Admission into labour:

Evaluate the client to decide mode of delivery depending on
• General health of the mother and the foetus
• Foetal position & presentation
• Obstetrical assessment (pelvis, cervical dilatation, vaginal bleeding & state of membranes)
iv) Efficient conduct of labour:

• accurate observations and their interpretation
• proper use of the partogram
• timely intervention
v) Well trained and skilled personnel in reproductive health care.
vi) Adequate adolescent care including nutrition and sex education.
vii) Education to the community on high risks of pregnancy
G). Special Notes on Obstructed Labour

Destructive delivery: Destructive deliveries have been performed on dead foetuses in cephalic presen-
tation or in breech when there are difficulties in the delivery of the after coming head. The decision to
perform destructive procedure as against Caesarean section must be taken in consideration of possible
maternal morbidity and disability and not for reasons of not giving the mother an abdominal scar. De-
structive operations should therefore be considered only in the following circumstances.
i) The foetus must be definitely confirmed dead.

ii) The presenting head must not be 2/5 or more above the brim.
iii) In breech presentation, other ways of delivering the after coming head should have failed
before resorting to destructive procedures.
NB: In general destructive vaginal delivery carries risk of severe morbidity and disability to the
mother both physically and mentally than obstructed labour itself.
43
5.2.2. SESSION 2: PROLONGED LABOUR
5.2.2.1. Session outline : 2h30

• Introduce session: Aim of the session……………………………….…………5 min
• Definition of prolonged labour…………………………………………..…..10 min
• Clinical presentation of prolonged labour……………………………………15 min
• Management of prolonged labour…………………………………………….60 min
• Complication of prolonged labour………………………………………..….30 min
• Prevention of prolonged labour………………………………………………30 min
5.2.2..2. Aim
The aim of this session is to enable participants to be able to recognise the clinical presentations
of obstetric labour define and to describe how to manage it.

• Define prolonged latent phase of labour
• Define prolonged active phase of labour
• To describe management of prolonged latent phase of labour
• To describe management of prolonged active phase of labour
• Outlined clinical presentation of prolonged labour
• Outlined complications of prolonged labour
• Outlined prevention measures of prolonged labour

A) Prolonged latent phase;
Definition: latent phase of labour lasting for more than 8hrs, the diagnosis is usually,
made retrospectively.
Management;
• Reassess the patient and rule out false labour
• If there has been a change in cervical effacement and dilatation rupture the membranes and
start oxytocin infusion to induce labour.
• Monitor foetal-maternal wellbeing
• Administer adequate IV fluids to prevent dehydration.
• If the woman has not entered the active phase after 8hrs of oxytocin infusion deliver by C/S
• If there are signs of infection (fever, foul smelling vaginal discharge) give triple
antibiotics; ampicillin, metronidazole and gentamycin.
• If the woman delivers vaginally discontinue antibiotics postpartum.
B) Prolonged active phase;

Definition: this is when cervical dilatation does not occur at the rate of at least 1.2 cm per an hour
in a nullipara or 1.5 cm per an hour in a multipara or if active phase last for more than 12 hours in
a nullipara or 6 hours in a multipara.
44
Management;
• Reassess the general condition of the patient and vital signs.
• Rehydrate the Patient with IV fluids
• If there are no signs of cephalo pelvic disproportion and obstruction and the membranes are
intact rupture the membranes.
- Assess the uterine contractions;

If the contractions are inefficient (3:10 lasting for less than 40secs) suspect inadequate uterine activity
and augment with oxytocin (depending on parity) drip with 2.5 - 5IU in multipara and 5-10 IU in
nullipara in 1L 5%Dextrose.
NB: Inefficient contractions are less common in multipara than primipara. Hence efforts
should be made to rule out disproportion in multipara before augmenting with oxytocin
- Reassess progress by vaginal examination 2 hours after good contractions have been established.
If there is no progress between examinations deliver by caesarean section.
If the contractions are efficient (3 or more contractions in 10 min each lasting for more than 40
sec) and still no progress, suspect CPD, obstruction, malposition or malpresentation.
Take patient for C/S.
For clinical Presentation, Complications and Prevention (refer to Obstructed Labour insert page)
5.2.3. SESSION 3: PREMATURE LABOUR

5.2.3.1. Session outline: 3hours
• Introduce session: Aim of the session…………………..……………..….…10 min
• Definition of premature labour……………………………….….………....10 min
• Risk factors predisposing to premature labour...............................................40 min
• Diagnosis and management of premature labour……………….….…….....90 min
• Complications of premature labour ...............................................................30 min
5.2.3.2. Aim
The aim of this session is to enable participants diagnose and manage premature labour.

• define premature labour;
• identify risk factors predisposing to premature labour
• diagnose premature labour
• discuss management of premature labour
• describe complications of premature labour
5.2.3.4. Content of the session:

A) Definitions: Premature labour is labour occurring after 24 weeks but before 37 weeks of gestation.
45
B) Risk factors predisposing to premature labour:
Maternal factors:
i) General medical/Surgical/Obstetrical
• Trauma
• Previous abortion
• pelvic genital infections
• general febrile infections e.g. malaria, pneumonia
• UTI e.g. Pyelonephritis
• HIV/AIDS
• anaemia
• previous premature delivery
ii) Uterine factors:

• incompetent cervix
• uterine abnormalities e.g. bicornuate, didelphys uterus
• tumours - uterine fibroids
iii) Socio-economic factors:

• age < 16 or above 35 years
• poor nutrition
• low maternal weight <50 kg
• smoking
• alcohol and drug abuse
iv) Psychological Factors

• emotional and physical stress
• anxiety
Foetal factors:
Placental related factors:
i) premature rupture of membranes
ii) placental abnormalities including abnormal placentation
Other factors:
i) multiple pregnancy
ii) polyhydramnios
iii) malpresentation
iv) congenital abnormalities
C) Diagnosis and management:

Diagnosis of premature labour is based on presence of regular uterine contractions, 2:10 minutes and
lasting for 20 to 30 seconds observed for at least 30 minutes, progressive cervical effacement,
cervical dilatation occurring after 24 weeks but before 37 weeks of gestation.
46
Investigations
• Obstetric Ultrasound
• FBC, U/E, X-match
• MSU
The management of labour and choice of mode of delivery is guided and dictated by:
• whether membranes are intact or ruptured.
• the absence or presence of haemorrhage; and if present the severity of it.
• the gestational age, estimated foetal size and foetal lie
• maternal and foetal condition
i) Amniotic Membranes:
• If premature labour occurs with ruptured membranes at gestation >33 weeks and or the
estimated foetal weight is >2,5kgs labour should be encouraged and delivery accomplished.
If membranes are intact and patient in an established labour an attempt should be made to
suppress labour. Efforts should be made to find the cause of premature labour.
• Premature labour with ruptured membranes: If labour is already established, management with
tocolytics to suppress labour is generally a futile exercice.
If the patient is not in established labour at a gestation <34 weeks efforts to suppress labour with
tocolytics for 24-48 hours during which time glucocorticoid is administered are justified. The
usefulness of glucocorticoids in gestations of <28 weeks is questionable. Patient should be put
on antibiotics.
ii) Haemorrhage:
Use of tocolytic and other agents to delay delivery is contra - indicated in the presence of
haemorrhage that threatens maternal and or foetal well-being.
iii) Gestational Age, Estimated Foetal Weight and Foetal lie:

These three parameters often dictate the mode of delivery.
iv) Maternal and Foetal Condition:

Certain maternal and foetal conditions are contraindications to the use of some tocolytic agents e.g.
Cardiac diseases and Diabetes. Careful assessment of the mother and foetus is mandatory and relevant
reference to stipulated tocolytic agent must be made.
Treatment
Drugs of Choice:
• Nifedipine
• Indomethacin: 100mg stat then 25mg qid for 48 hours.
• Broad spectrum antibiotics - IV, IM or oral
• Glucocorticoid: dexamethasone, betamethasone - IM.
47
NIFEDIPINE PROTOCOL
In order to prevent or delay preterm labour Nifedipine may be used as a tocolytic drug of first choice
as it has been shown to be the most effective with the least side effects. The aim of tocolysis is to gain
time for steroids administration, hence women should be on tocolysis without steroids.
Dexamethazone is given at 12mg IM 12 hours apart; weekly repetition is not advised (no
proven benefit to the foetus).
Tocolysis is indicated in pregnancies below 34 weeks of gestation, contraindicated in cases

of chorioamniotis (such patients should be delivered as soon as possible). Tocolysis should
be discontinued after 48 hours as longer use has not been shown to be benefit.
A significant proportion of patients with preterm labour have a subclinical chorioamniotis, hence
antibiotics should be given together with tocolysis (Erythromycin 500 mg 6 hourly for 7 days or
Amoxycillin 500 mg 8 hourly for 7 days) irrespective of whether or not membranes are ruptured, Urine
for MCS should be collected before antibiotics are started.
Dose of Nifedipine
20 mg orally stat followed by 20 mg orally after 30 minutes, then followed by 20 mg every 4 - 8 hours
for maximum of 48 hours.
The maximum dose is 160 mg per day

To be discontinued once contractions have ceased
No maintenance treatment beyond 48 hours
Contraindications: allergy to Nifedipine, hypotension, hepatic dysfunction, underlying cardiac

lesions, concurrent use of beta-mimetic
Side Effects: hypotension, tachycardia, palpitations, flushing, dizziness, nausea
Monitoring: Maternal Pulse Rate and BP every 30 minutes for the first hour, then hourly for the first
24 hours, then every 4 hours.
Foetal well being every 30 minutes
D) Complications
i) Pyschological stress
ii) Infection
iii) Prematurity and its associated complications
iv) Retained placenta
v) Postpartum Haemorrhage
E) Special notes on premature labour:

• If premature labour is diagnosed in latent phase and with intact amniotic membranes efforts
should always be made to stop it. However because often the premature labour may recur after
the initial successful treatment it is useful and wise to give dexamethasone to the mother as part
of the initial treatment to facilitate foetal lung maturity.
48
• When premature labour occurs at the gestation of 28 to 34 weeks with ruptured membranes and
in latent phase, the patient should receive dexamethasone among other treatments. The risk of
intrauterine and or puerperal infection should supersede the respiratory distress syndrome.
The continuation of conservative treatment for premature labour with ruptured membranes at
a gestation of less than 34 weeks will depend on whether the draining of liquor stops within 48
hours of the treatment. Failure calls for delivery.
• One of the common causes of premature labour is bacterial infections particularly where
there is rupture of membranes. In all these cases, therefore, both mother and child should
receive prophylactic antibiotics to cover gram positive and negative bacteria.
• Continuing the conservative management for more than 48 hours with persistence drainage of
liquor places the foetus at the risk of intrauterine death due to complete drainage of liquor that
exposes both the foetus and the placenta to intrauterine compression.
• Established active labour will not be suppressed by medication. Such medications (tocolytics and
sedatives) will only prolong labour, which poses serious risks to the premature foetus and the
mother. In such cases, labour should be allowed to progress and monitored as described.
• In premature labour with intact membranes, the artificial rupture of the membranes should be
delayed, if possible up to when cervical dilatation reaches 6 -7 cm. During ARM, caution must
be taken against cord prolapse.
49
Flow Chart N0. 5
F. MANAGEMENT OF PREMATURE LABOUR : LABOUR NOT ESTABLISHED
Premature Labour not

in established labour
Exhaustive history, physical

examination, Speculum
exam, intra cervical swab for
MCS, Information education
and counselling
Membranes intact Membranes ruptured
Bedrest, hydration, Bedrest, antibiotics

tocolytics hydration, tocolytics,
dexamethasone if indicated dexamethasone if indicated
No
Membranes intact Continue bedrest High rupture, Continue to drain
await labour drainage stops, consider delivery
Yes No contractions within 48 hours avail
incubator prepare
resuscitation or refer.
Treatment Treatment fails

successful, take and labour
pregnancy to restarts.
term
Labour as per
partogram
or deliver as
appropriate (c/s?)
or refer avail
incubator prepare
resuscitation
50
Flow Chart N0. 6
D. MANAGEMENT OF PREMATURE LABOUR : LABOUR ESTABLISHED
Premature Labour in
established labour
Exhaustive history, physical

exam , Speculum exam,
intracervical swab, IEC
Membranes ruptured Membrane intact
Antibiotics, encourage labour, Defer ARM as far as possible.

follow PMTCT protocol Follow PMTCT protocol
Monitor labour, prepare for Monitor labour prepare for

resuscitation warm incubator resuscitation, warm
or refer. incubator or refer.
51
5.3. MODULE 3: MANAGING HYPERTENSIVE DISORDERS IN PREGNANCY (HDP)
SUMMARY OF THE MODULE: 8hours
SESSION TEACHING - LEARNING TIME FRAME

METHODS Total: 8hours
1. Defining and classification of Modified Lecture, Discussion 1h

hypertensive disorders in preg-
nancy (HDP)
2. Pregnancy Induced Hyper- Modified Lecture, Group Work, 2h
tension Feedback, Discussion
3. Pre-eclampsia and severe Modified Lecture, Case Study, 2h

pre-eclampsia Feedback, Discussion
4. Eclampsia Modified Lecture, Demonstra- 2h

tion, Discussion
5. Complications of pre-ec- Modified Lecture, Role Play 1h

lampsia and eclampsia Discussion
5.3.1. SESSION 1: DEFINING AND CLASSIFICATION OF HYPERTENSIVE

DISORDERS IN PREGNANCY

• Introduce session: Aim of the session…………………….……………….……..10 min
• Definition of hypertensive disorders in pregnancy……………….………….....30 min
• Types/classification of HDP….…………………………………..……….…….20 min
5.3.1.2. Aim
The aim of this session is to enable learners to diagnose and explain the clinical characteristics
of various types of HDP.

On completion of this session, learners will be able to:
ß Define hypertension in pregnancy, pregnancy induced hypertension, pre-eclampsia, and eclampsia;
ß Outlined types/classification of HDP

A) Hypertension in pregnancy is defined as :
• Diastolic blood pressure of at least 90mmHg or systolic pressure of at least 140mmHg. These blood
pressures must be recorded on at least two occasions 4-6 hours apart.
52
• Elevation of more than 30mmHg systolic or more than 15mmHg diastolic above the patients baseline
in other consideration.
N.B. Diastolic blood pressure alone is an accurate indicator of hypertension in pregnancy.

Elevated blood pressure and proteinuria, however define pre-eclampsia.
B) TYPES/CLASSIFICATION OF HDP
This table depends on the occurrence of hypertension (HPT), the presence or absence of
proteinuria and presence of symptoms of pre – eclampsia.
Type Clinical Characteristics
1. Pre-eclampsia (Gestational proteinuric Hypertension with proteinuria from 20 weeks. (protein

HPT) ≥1+ dipstix or 300mg / 24hrs urine).
2. Gestational Hypertension Pregnancy Hypertension without proteinuria and detected from 20
induced HPT weeks of gestation.
3. Transient Hypertension Hypertension developing during labour or soon after

delivery in women with no prior signs of pre-eclampsia
or hypertension and disappears within 12 wks post
partum.
4. Chronic Hypertension Hypertension, pre-existing or occurring prior to 20
weeks gestation or persisting beyond pueperium.
5. Super-imposed Pre -eclampsia Pre-eclampsia in women with chronic hypertension.
6. Eclampsia Seizures attributed to pre- eclampsia and no other

cause.
i) If a woman has any one of the symptoms or signs listed under severe pre-eclampsia,
diagnose severe pre-eclampsia.
ii) If a diagnosis of eclampsia cannot be ruled out, continue treatment for eclampsia
Headaches, blurred vision, convulsions and loss of consciousness are often associated with
hypertension in pregnancy. Other conditions that may cause convulsions or coma include epilepsy,
complicated malaria, head injury, meningitis and encephalitis.
5.3.2. SESSION 2: DIAGNOSIS AND MANAGEMENT OF PREGNANCY-INDUCED

HYPERTENSION
5.3.2.1. Aim
The aim of this session is to enable participants to diagnose and manage pregnancy induced
hypertension (PIH).
53
5.3.2.2. Session outline : 2hours
• Introduce session: Aim of the session……………………..………………..….20 min
• Diagnosis of PIH……………………………………………………………….40 min
• Management of pregnancy induced hypertension (PIH)..………………….....60 min

On completion of this session, participants will be able to:
• Recognise the manifestations of PIH
• Discuss and describe the management of PIH;

A) DIAGNOSIS
• Two readings of diastolic blood pressure of 90-110 mmHg 4 hours apart after 20 weeks of gestation
• No proteinuiria
In pregnancy induced hypertension, there may be no symptoms and the only sign may be hypertension:
B) MANAGEMENT
Patient who are admitted with mild hypertension should be observed for 24 hours. If the BP settles,
the patient will not require antihypertensive medication. If BP not settled give:
Antihypertensive
• Methyldopa (aldomet): 500mg tds as a drug of choice for prolonged treatment. The dosage can be
increased to qid and or 750mg
• Monitor blood pressure, urine for proteinuria and foetal condition weekly.
• If blood pressure worsens, manage as mild pre-eclampsia
• If there are signs of severe foetal growth restriction or foetal compromise, admit the woman to
the hospital for assessment and possible expedited delivery
• Counsel the woman and her family about danger signs indicating pre-eclampsia or eclampsia
• In case of mild PE, when BP is controlled and renal function acceptable, and there is no IUGR, the
woman should be delivered at 37 completed weeks of gestation and pregnancy should not
continue past 40 weeks.
• If there is IUGR before 34 weeks of gestation give glucosteroids and deliver the woman. If
gesta-tion is after 34 weeks and there is IUGR, deliver. A favourable cervix may undergo
induction of labour, but if the conditions of induction are not favourable deliver by c/section.
• Blood for FBC, U/E, LFT, Uric Acid
5.3.3. SESSION 3: MANAGEMENT OF PRE-ECLAMPSIA AND SEVERE PRE-ECLAMPSIA
5.3.3.1. Aim: 2hours

The aim of this session is to enable participants to diagnose and manage PE and Severe Pre-Eclampsia.
5.3.3.2. Session outline

• Introduce session: Aim of the session………………………..……………….…10 min
• Diagnosis of pre-eclampsia and severe pre-eclampsia….......……………....… 50 min
• Management of pre-eclampsia and severe pre-eclampsia……..……….............60 min
54
• Recognise the manifestations of pre-eclampsia and severe pre-eclampsia
• Discuss and describe the management of PE and severe pre-eclampsia;

A) Signs and Symptoms of PE
• Elevated BP – Diastolic of > 110mmHg
• Proteinuria >2+ on dipstick, > 5g in 24 hours urine specimen
• Oliguria: less than30 ml per hour, or <500mls urine output in 24 hours
• Cerebral or visual disturbance, epigastric pain, cyanosis or pulmonary oedema may or may not
be present
• Oedema: anasarca, pulmonary oedema are obvious signs of pre-eclampsia.
• Patients diagnosed with severe pre-eclampsia should ideally be hospitalized for evaluation of
mater-nal and foetal conditions
B) Management
N:B: The cure of severe pre-eclampsia and eclampsia is delivery of the foetus and placenta.
• Insert IV cannula and collect blood specimen for FBC, X-Match, U/E, LFT, Uric Acid
and Coagulation profile.
• Urine for analysis – dipstick and 24 hr urine specimen for protein
• Treat hypertension accordingly, give hydralazine 12.5 mg IM if diastolic BP is > 110mmHg,
give methyldopa 500mg TDS or 750mg QID
• Give steroids to promote lung maturity in a foetus of gestational age of <34 weeks.
• Strongly consider the need for magnesium sulphate, give if eclampsia is imminent i.e presence
of headache, blurred vision, epigastric pain and brisk reflexes, and in all cases of eclampsia
• If BP is not controlled, proteinuria persists and the liver and renal functioning is
deteriorating, deliver the woman.
Insert flow charts pg 104 and 105
5.3.4. SESSION 4: DIAGNOSIS AND MANAGEMENT OF ECLAMPSIA
5.3.4.1. Aim : 2hours

The aim of this session is to enable participants to diagnose and management of eclampsia.

• Introduce session: Aim of the session……………………..……………….…..10 min
• Diagnosis of eclampsia…………………………………………………….......50 min.
• Management of eclampsia…………………………..…………………….…....60 min

• Recognise the manifestation of eclampsia
• Discuss and describe the management of eclampsia;
55
A) Signs of Eclampsia:
The presence of convulsions during pregnancy, delivery or in the pueperium is diagnosed as
eclampsia until proven otherwise. Signs and symptoms of pre-eclampsia may be present.
The BP might be within normal ranges.
Differential diagnosis:
• Epilepsy
• Cerebral malaria
• Septicaemia
• Meningitis
• Encephalitis
B) Management:
• CALL FOR HELP, do not leave the woman alone
• Place the woman in the left lateral position
• Maintain patency of airway at all times new roman new roman, provide oxygen
• Control convulsions and prevent their recurrence with magnesium sulphate for 24 hours
• Insert IV cannula using a large bore needle, collect blood for FBC, grouping and cross match, U/E,
LFT and coagulation profile and give fluids (normal saline or R/lactate) while maintaining a strict
fluid balance chart to prevent fluid overload. Ensure the availability of 2 units of whole blood.
• Insert an indwelling urinary catheter to monitor urinary output (urine output should not be less
than 30mls per hour) and proteinuria.
• Withhold magnesium sulphate if any of the following signs occur:
- absence of knee jerk reflex
- urine output less than 30mls per hour
- respiration < 12b/m
NB: In absence of knee jerk reflex and respiration <12b/m give antidote calcium gluconate 10mg
IV slowly. In case of urine output less than 30mls per hour infuse IV fluids (N/saline or R/lactate)
at 1 litre in 8 hours (125mls/hour), monitor for the development of pulmonary oedema.
• Auscultate the lung bases hourly for rales indicating pulmonary oedema. If rales are heard, with-
hold fluids and give furosemide 40mg IV stat.
• Monitor BP every 15 minutes and give hydralazine PRN.
• Assess the clotting status with a bedside clotting test. Failure of clot formation after seven minutes
or a soft clot that breaks down easily suggests coagulopathy
• Assess for urgent delivery. Delivery must be contemplated irrespective of foetal maturity. Both
maternal and foetal well being is in jeopardy. The first priority is to control the fits and or prevent
further occurrence with magnesium sulphate. Concurrently BP should be stabilized and delivery
options considered.
56
C. ECLAMPTIC PACK
• Magnesium sulphate sufficient for loading dose
• Calcium gluconate
• Nifedipine and methyldopa
• Hydralazine injection
• IV fluids 1 litre (normal saline or R/lactate)
• IV cannula x 2 (size 16 or 18)
• Fluid giving set
• A pair of gloves
• Folley’s catheter and urobag
• Airway
• 02 mask and oxygen
D. DRUG OPTIONS
i. Hydralazine
6.25 – 12.5 mg IM in cases of diastolic BP > 110mmHg
ii. Antihypertensive
Methyldopa (aldomet): 500mg tds as a drug of choice for prolonged treatment: The dosage can be
increased to qid and or 750mg
iii. Magnesium Sulphate

Loading dose of magnesium sulphate:
5 grams = 10mls + 1.0 ml of lignocaine deep im right buttock
5 grams = 10mls + 1.0 ml of lignocaine deep IM left

buttock 4 grams = in 200mls dextrose slowly IV
Maintenance dose until 24 hours after the last fit

5g = 5 ampules = 10mls + 1.0 ml lignocaine 4 hourly deep in alternate buttocks
NB:
• Ensure a patient is nursed in a high dependency area or intensive care unit for 24 hours or
until condition is improved and stable following delivery.
• Continue antihypertensive therapy accordingly
• Provide counselling and information to the patient on her condition, contraception and
future pregnancies prior discharge
57
5.3.5. SESSION 5: MANAGEMENT OF COMPLICATIONS OF PRE-ECLAMPSIA AND
ECLAMPSIA
5.3.5.1. Aim : 1hours

The aim of this session is to enable participants to recognise the main complications of pre-
eclampsia and eclampsia and to be able to transfer them on time to specialised services.
• Introduce session: Aim of the session……………………..……………….…10 min
• Diagnosis of the main complications of PE and eclampsia……………………20 min.
• Management of the complications of PE and eclampsia …..………………...30 min

• Recognise the manifestations of the main complications of PE and eclampsia
• Describe the management of these complications

A. The HELLP syndrome
H= Hemolysis, EL = Elevated Liver enzymes, LP=Low Platelets
Criteria to establish the diagnosis of HELLP Syndrome:

• Hemolysis: - Hemolytic anaemia
- Abnormal peripheral blood smears
- Increased billirubin > 1.2 mg/dl
• Elevated liver enzymes:

- Increased SGOT > 72 IU/L
- Increased lactic dehydrogenase > 600 IU/L
• Thrombocytopenia: Platelet count <100, 000/mm3
Transfusion of blood products (packed erythrocytics, fresh plasma, or platelets)
• Refer/transfer to a specialized service
This syndrome is associated with poor maternal and foetal outcome and its severity
requires specialized attention.
B. Acute oedema of the lung

• Half-sitting position
• Oxygen therapy 3 - 6 litres/minute (non-invasive artificial ventilation) ;
Furosemide 20 mg vial: 2 - 4 vials in IVD, to be renewed 30 min later if
insufficient response
• Refer/transfer to a specialized service
C. Acute kidney failure

Especially in pre-eclamptic patients with high BP before pregnancy.
• 20 mg furosemide vial: 2 - 4 vials in IV dextrose, to be renewed 30 minutes later if
insufficient response
• Refer/transfer to specialized unit.
58
D. Postpartum Care
• Continue to monitor the BP 6 hourly
• Monitor for signs and symptoms of imminent eclampsia
• Repeat blood investigations (FBC, grouping and cross match, U/E, LFT and
coagulation profile) and urinalysis
• Chest x-ray for patients who had pulmonary oedema
• Discharge of the patient will depend on the clinical condition
E. Special notes
• The use of diuretics in PE is not recommended except if there is pulmonary oedema and
cardiac failure.
• When patients develop eclampsia, the first priority is to control the fits and or prevent further
occurrence with magnesium sulphate, concurrently BP should be stabilized and delivery
options considered. Urgent delivery must be contemplated irrespective of foetal maturity.
Some cases of PE can be complicated by HELLP syndrome (Haemolysis, Elevated Liver Enzymes
Low Platetelets) clinical signs include malaise, epigastric pain, nausea, vomiting, jaundice.
HELLP syndrome is associated with poor maternal and foetal outcome. The severity of HELLP
syndrome requires specialist attention.
5.4. MODULE 4: MANAGING SEPSIS IN OBSTETRICS

This module is to enable participants to understand that it is possible that many infections and parasitic
diseases and their associated risks can attack the woman during pregnancy and post partum period,
and the importance of early diagnosis and management is to save life.
SUMMARY OF THE MODULE 4: 5 hours
SESSION TEACHING-LEARNING TIME FRAME Total: 5 hours

METHODS
1. Define and classify Sepsis in Modified Lecture, Discussion 30 min

Pregnancy
2. Causes, Diagnosis and Modified Lecture, Group Work, 1 h

management of infections in Feedback, Discussion
pregnancy
3. Causes, Diagnosis and Modified Lecture, 1h
management of abortal sepsis Demonstration, Discussion
4. Causes, Diagnosis and Modified Lecture, Case Study 1h

management of puerperal sepsis Discussion
5. Complications of Sepsis in Modified Lecture, Role Play 1 hour 30 min

obstetrics and Septic Shock Discussion
5.4.1. SESSION 1: DEFINE AND CLASSIFY SEPSIS IN OBSTETRICS.

• Introduce session: Aim of the session……………………..…………………5 min
59
• Definition of sepsis in pregnancy, childbirth and postpartum……………. 15 min
• Types/classification of sepsis in obstetrics....………………....…………..….10 min
5.4.1.2. Aim
The aim of this session is to enable participants to define and classify the various types of sepsis
in obstetrics.

• Define Sepsis in obstetrics;
• To define various types of sepsis in obstetrics, during pregnancy, childbirth and postpartum.

A) DEFINITIONS
Sepsis is a pathologic state resulting from the presence of micro-organisms or toxins in the blood
stream
Septicaemia is the presence of bacteria in the blood (bacteraemia) and is often associated with severe
infections
B) CLINICAL CLASSIFICATION
i) Infections in pregnancy
ii) Pueperal sepsis: sepsis associated with delivery and post delivery state. The commonest types of
puerperal sepsis are:
• Mastitis – when infection is localized to one or both breasts
• Pelvic abscess – the infection is localized in the pelvic region after uro-genital system is involved.
• Septicaemia with or without bacteraemia –multiple organs and system are involved
iii) Abortal sepsis: sepsis related to abortion
5.4.2. SESSION 2: CAUSES, DIAGNOSIS AND MANAGEMENT OF

INFECTIONS IN PREGNANCY
5.4.2.1. Aim
The aim of this session is to enable participants to manage the main infections during pregnancy.
5.4.2.2. Session outline: 1hour

• Introduce session: Aim of the session………………..………………….…5 min
• Causes of infections in pregnancy………………………………………...10 min
• Signs and symptoms of infections in pregnancy………………………….15 min
• Differential diagnosis …………………………………………..…….. 10 min
• Management of infections in pregnancy…………………………………..20 min

60
• Discuss causes of infections in pregnancy
• Discuss predisposing factors of infections in pregnancy
• Outline signs and Symptoms of infections in pregnancy
• Mention differential Diagnosis
• Discuss management of infections in pregnancy
5.4.2.4. Content
A) Causes and clinical presentation of antenatal infection
Infection Cause Predisposing factors Signs & Symptoms
Trichomoniasis Trichomonias Sexual intercourse Genital irritation
vaginalis Poor personal hygiene Fetid foamy or
Common sitting Greenish P.V
Toilets discharge.
Common bath tabs Reddish petenchiae on
cervix or vagina.
Candidiasis Candida albicans Sexual intercourse Genital pruritis
Poor personal Curdy white
hygiene PV discharge
Diabetes mellitus Vulvo-vaginitis
Swelling of the vulva
Non-specific Non-specific pathogens Poor personal hygiene Offensive P.V.
Vaginitis and Cervicitis Vaginal douching Discharge
Anaemia
Cervical erosion.
UTI (Cystitis and Bacteria (Ecoli) Poor hygiene Dysuria, increased

pyelonephritis) diabetes frequency and urgency
Urinary stasis of urination.
Obstructive Loin pain/tenderness
urophathies Nausea/vomiting
Tenderness in rib cage
Foul smell urine
B)MANAGEMENT OF INFECTIONS IN PREGNANCY
INVESTIGATIONS
• Urinalysis
• HVS or pus swab for culture and sensitivity
• FBC, cross match
• U/E
• LFT
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• HIV testing
• Blood culture
• Ultrasonography of the abdomen and pelvis
• Random blood sugar
C) TREATMENT
Infections in Pregnancy
Specific treatment is best prescribed after results of the investigations are received. However, immedi-
ate treatment may be necessary and the general treatment recommended is as follows:
• Antimycotics: Clotrimazole pessaries and cream. This also relieves general symptoms.
• Anti - trichomonas: The safety of metronidazole in pregnancy is not assured; therefore it should
be avoided in the first trimester.
• Antibiotics: Ampicillin, cloxacillin, ampiclox, penbrittin etc.
The treatment of specific infections must include concurrent treatment of the partner even if the
partner has no symptoms.
5.4.3. SESSION 3: MANAGING ABORTAL SEPSIS
5.4.3.1. Aim :
The aim of this session is to enable participants to manage abortal sepsis.
5.4.3.2 Session outline: 1 hour

• Introduce session: Aim of the session…………………..…………….…5 min
• Clinical presentation of abortal sepsis.............................................……15 min
• Management of abortal sepsis...................................................................30 min
• Prevention of abortal sepsis……………………………………………..10 min

• Describe clinical presentation of abortal sepsis
• Discuss management of abortal sepsis
• Discuss prevention of abortal sepsis
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5.4.3.4. Content of the session:
Unsafe abortion is the commonest source of abortion related sepsis. Therefore, all types of abortions,
should be considered as potentially infective conditions since the environment in which they start and
develop are uncertain.
A) Table N0.1: Clinical Presentation

Severity of Sepsis Symptoms Signs
Mild Headache . Fever and hypothermia
. Lower abdominal pain . Brownish or blood stained
. Thirst purulent vaginal discharge
. General body malaise . Suprapubic tenderness
. Nausea and vomiting . Pelvic tenderness
. Dysuria . Positive cervical excitation
. Occasional diarrhoea . Dehydration
Severe sepsis . All of the above symptoms . Rigor
. Dizziness . All the above signs except de-
hydration which may be severe
. Oliguria
. Jaundice due to haemolysis
. Abdominal tenderness and
guarding
. Abnormal pulse rate
Very severe (shock) = Patient may be . Marked paleness
septic shock = disorientated or unconscious. . Cyanosis
endotoxic shock . High fever with rigors or . Pupils may be dilated
hypothermia. . Pulse-weak, rapid
. BP may be lowered
. Restlessness
. Hyperventilation
. Tachycardia
. Severe jaundice
. Renal failure
B) Management of abortal sepsis
Investigations
i) Basic investigations include: Urinalysis
Full blood count
HVS for culture and sensitivity
U/E
LFT
Pregnancy test
HIV testing
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ii) Advanced investigations: Blood culture
Ultrasonography of the abdomen and pelvis
Blood gases
Coagulation
X-ray of the chest and abdomen
Principles of Management
i) Hydration of the patient is of cardinal importance. Avoid cardiac overload.
ii) Aggressive antibacterial therapy must be instituted immediately and adjusted accordingly after
the sensitivity reports are received. Usually triple antibiotic therapy is prescribed.
iii) Fresh blood and or blood products (plasma, packed blood cells) should be made available
and ready for possible administration.
C) Prevention of abortal sepsis:

• Spontaneous abortions are generally unexpected events and often occur in potentially infective
environment. Unsafely induced abortions are even more so. It is therefore safe to regard them as
infected conditions at the time of diagnosis and provide wide spectrum antibiotic treatment.
• The specific and definitive management of the various clinical types of abortion must be
initiated promptly without undue delay.
• Education and counselling on personal and sexual hygiene for pregnant women right from the
beginning of the pregnancy will help to minimize the chances of sepsis if abortion may occur.
• Comprehensive post abortal care
5.4.4. SESSION 4: MANAGING PUERPERAL SEPSIS
5.4.4.1. Aim
The aim of this session is to enable participants to manage puerperal sepsis.
5.4.4.2 Session outline: 1hour

• Introduce session: Aim of the session…………………..…………….…5 min
• Definition of puerperal sepsis...................................................................... 5 min
• Classification, diagnosis and predisposing factors of puerperal sepsis…15 min
• Management of puerperal sepsis............................................................... 30 min
• Prevention of puerperal sepsis................................................................... 5 min

• Describe clinical presentation of puerperal sepsis
• Discuss management of puerperal sepsis
• Discuss prevention of puerperal sepsis
5.4.4.4. Content of the session

Puerperal sepsis is an infection of the genital tract which occurs as a result of complications
of delivery.
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A) Table N0.2 Classification of puerperal sepsis and management
Diagnosis and Signs and Symptoms Predisposing factors and conditions Management
Ultrasonogaph
Endomeometritis: Poor personal hygiene Blood investigations
Chest X-ray
Rehydrate the patient
Temp 38°C and above six hours Repeated vaginal exam IV Triple antibiotics
(ampicillin, gentamicin and
after delivery Prolonged labour metronidazone)
Manage according to cause
Malaise,LAP C/section -if RPOCs, then evacuate
-if no improvement, perform
laparatomy
Offensive lochia
Uterine subinvolution
Infected wounds Poor personal hygiene Sitz baths

Vulval toilet/swabbing
Temp 38°and above Repeated vaginal exam Antibiotics
Wound care
Malaise Wound swab for Culture and sensitivity
Tenderness
Swelling
Discharge/pus
Mild Sporadic Mastitis
Mastitis- (may be mild or severe with - Nursing mothers Continue breastfeeding
abscess) - Galactostasis in the . Culture of nipple discharge or milk
breast . Broad spectrum antibiotics & analgesics
-Breast engorgement - Cracked nipples . Topical cream for the treatment of
- Segmental erythema - Breast tumours cracked nipples
- Tenseness in breast - Staphylococcus . Cold compresses and firm Brassiere.
- Axillary adenopathy aureus. Severe mastitis with abscess formation
- Fever, but not always - Oral thrush on the baby Prompt weaning in case of abscess or
- Nipple purulent discharge
temporary suspension of breastfeeding
(not always) . Broad spectrum antibiotics
. Cold compresses and supporting
Brassiere.
-Ultrasonograph
Pelvic sepsis
- Pelvic pain - Prolonged labour -Blood investigations
- Lower abdominal pain - Obstructed labour -Chest X-ray
- Dysuria (urethral pain - Premature rupture of
during urination) membranes -Rehydrate the patient
- Copious purulent or - APH
brownish lochia - Pre-existing lower genital -IV Triple antibiotics
- Fever infections (ampicillin, gentamycin and
- Lower abdominal - Lack of conformity to
tenderness asepsis in the metronidazole)
- Pelvic tenderness management of labour
- Infected and opened up and delivery. -Manage according to cause
genital wounds. - Difficult vaginal delivery -if pelvic abscess, perform
(episiotomies, - Poor repair of
perineotomies). lacerations. laparatomy and drain pus
- HIV
Septicaemia - As in pelvic sepsis See management of septic shock
- Exaggerated signs and - Inefficient management
symptoms of pelvic sepsis of puerperal pyrexia i.e
- Generalized body pain neglected puerperal
- Symptoms and signs of sepsis
peritonitis:
vomiting, severe - Inaccessibility to PNC.
abdominal guarding,
dehydration.
- Olyguria
- Renal failure
- Jaundice
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B) General Management of Puerperal Sepsis
When appropriate diagnosis and treatment is initiated early puerperal sepsis is less likely to
degenerate into septicaemia, peritonitis and formation of abscesses.
i). Once a clinical diagnosis has been made the following laboratory
investigations should be requested for:
• Urinalysis, MSSU for culture
• Endocervical swab for culture
• Full blood count
• Blood urea and electrolytes
In severe cases where pelvic or abdominal abscesses are suspected, in addition to these the
following should be considered:
• Blood culture
• Blood gasses
• Ultrasound of the abdomen with focus on pelvis where this is possible.
• Abdominal X-ray
• HIV counselling and testing
ii). Meanwhile the patient should be commenced on:

• broad spectrum antibiotics to cover for gram-positive, gram-negative and
anaerobic microorganisms
• multivitamin therapy
• adequate hydration
• appropriate correction of anaemia if present.
iii). As soon as results from the tests are available including culture report the treatment must
be reviewed and adjusted accordingly.
iv). The necessity and frequency of repeat tests should be dictated by the condition of the patient
and response to therapy.
v). If abscesses have formed the patient should have laparotomy and drainage of the abscess as soon
as the patient’s conditions allows surgery under general anaesthesia. Failure to intervene surgically in
time leads to serious long-term complications.
C)Prevention
Prevention of puerperal sepsis is about guarding against predisposing factors.
• Promote good personal hygiene
• Avoid repeated vaginal exam
• Proper management of labour
• Proper identification of risk factors
• Encourage good nutrition
• Proper management of PROM, UTI and APH
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SESSION 5: COMPLICATIONS OF SEPSIS IN OBSTETRICS
AND MANAGEMENT OF SEPTIC SHOCK
5.4.5.1. Aim
The aim of this session is to enable participants to identify the complications of sepsis in obstetrics
and manage septic shock.

• Introduce session: Aim of the session…………………..…………….……10 min
• Complications of sepsis in obstetrics ……………………………………...30 min
• Septic shock………………………………………………………………..50 min

• Identify the complications of sepsis in obstetrics
• Define septic shock
• Identify signs and symptoms of septic shock
• Manage septic shock
5.4.5.4. Content of the Session

A) Complications of sepsis in obstetrics:
i). Antenatal infections:
• abortion and premature labour,
• premature rapture of membranes,
• congenital infection of the newborn (neonatal, septicaemia),
• may lead to puerperal sepsis.
ii) Abortal and puerperal sepsis:

• inability to provide adequate breastfeeding,
• infertility due to tubal blockage and or uterine synechia,
• maternal mortality.
NB: Septic Shock is a major complication of sepsis in obstetric which contributes to

maternal mortality.
B) SEPTIC SHOCK
A state of shock associated with bacteria or bacterial products in the blood
stream. Signs and Symptoms of Septic Shock
• Disorientation or unconsciousness
• Fever with rigors or hypothermia
• Pallor
• Cyanosis
• Hypotension
• Tachycardia
• Hyperventilation
• Jaundice
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• Renal Failure
• Dilated Pupils
Management of Septic Shock

• To resuscitate the patient
• To empty the uterus
• To remove the septic focus
• Shout for help for at least 2 assistants
• Establish a patent airway (without mobilise oxygen and give if necessary)
• Check blood pressure, pulse and temperature and respiration
• If consciousness, turn onto her left lateral position to minimize the risk of aspiration
• Elevate the foot end of the bed to increase blood to the heart.
• Secure IV line using a large-bore cannula, if you fail call for expert help.
• Collect blood for investigations
• Rapidly infuse IV fluids – crystolloids (Normal Saline or Ringers Lactate) 1 litre in 15 minutes.
Give 2litres in the first hour.
• Catheterize the bladder and monitor fluid intake and urine output
• Give intravenous antibiotics as follows:
- Ampicillin 2g or penicillin G 2m.n six hourly
- Gentamycin 5mg/kg body weight IV every 24 hours
- Metronidazole 500mg IV eight hours
NB: Cephalosporins may be preferred in some situations. A complete course of antibiotics must
continue for at least seven days even if the fever has subsided.
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5.5. MODULE 5: MANAGING NEONATAL
COMPLICATIONS SUMMARY OF THE MODULE. 3 hours
SESSION TIME FRAME TEACHING-LEARNING Total: 8 hours

METHODS
1. Managing Neonatal Asphyxia Modified Lecture, 50 min
Demonstration, Discussion
2. Managing Neonatal Infection Modified Lecture, Group Work, 40 min
Feedback, Discussion
3. Managing Premature Baby Modified Lecture, Case Study, 50 min
Discussion
4. Managing Neonatal Modified Lecture, Discussion 40 min
Hypoglycaemia
5.5.1. SESSION 1: MANAGING NEONATAL

ASPHYXIA 5.5.1.1. Session outline : 50 min
• Introduce session: Aim of the session………………………..…………………..… 5min
• Definition of neonatal asphyxia……………………………………….…………...10 min
• Diagnosis of neonatal asphyxia ……….………………………………….. …..…10 min
• Management of neonatal asphyxia ………………………………………………..25 min
5.5.1.2. Aim
The aim of this session is to train participants on basic procedures to follow when resuscitating a
newborn and to strengthen management of asphyxia through the use of existing clinical guidelines.

• Define neonatal asphyxia;
• Describe signs and symptoms of neonatal asphyxia;
• Discuss the management of neonatal asphyxia.

A) Definition: Failure of the baby to breath or initiate and sustain spontaneous respirations at
birth. NB: All high risk deliveries result in a greater risk for birth asphyxia and these are;
• thick meconium after membranes have ruptured
• fetal distress
• emergency caesarean section
• premature birth
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B) Diagnosis
As per degrees of asphyxia
Apgar score 4/10 - 7/10: mild Apgar score 0/10 - 3/10: severe
Baby is blue Baby is pale or cyanosed due to vasoconstriction
Apneoc Heart beat is slow, weak and or absent
Fairly strong heart rate less than 100b/m Flaccid muscle tone or no response to stimuli
Reduced muscle tone Baby does not attempt to breath
Sluggish response to stimuli
Efforts to breath are made
NB: Apgar score 8/10 and above is optimum. A baby with this score will /have pink body, blue
extremities, breath spontaneously, good cry, good muscle tone, heartbeat more than 100b/m,
active and responds to stimuli
C) Management of Severe Asphyxia

ABCD of resuscitation = Airway, Breathing, Circulation and Drugs
Immediate Action:
• Keep warm and use dry towels
• Extend the neck backwards
• Clear airway
• Suck mucus blood, mucus or meconium gently
• Intubation and ventilation (use ambu-bag with reservoir to give 100% O2)
• Obtain good circulation
• If heart rate is less than 100b/m, external cardiac massage at about 120 beats per minute
Drug Therapy
• Give: Epinephrine 1:10,000 (increases heart workload and improves O2 consumption)
• If mother was given Pethedine or Morphine before, give Naloxone 0.1mg/kg IM
or per umbilical vein
• Sodium bicarbonate 4ml/kg of 4.2% solution per umbilical vein slowly
Other drugs to consider:

• Phenobarbitone 20mg/kg IV slowly
• Use plasma expanders like Ringers Lactate or Normal Saline 5-10 minutes (10mls/kg)
per umbilical vein.
NB: Signs of successful resuscitation: restore three most important vital signs of the APGAR score;
i) Heart rate of more than 100b/min
ii) Good cry or good breathing efforts
iii) A pink tongue (shows O2 supply to the brain)
5.5.2. SESSION 2: MANAGING NEONATAL

INFECTIONS 5.5.2.1. Session outline : 40 min
• Introduce session: Aim of the session………………………..…………………….…5 min
• Definition of neonatal infections.……………………………………….……..........10 min
• Diagnosis of neonatal infections ……….…………………………………........…..10 min
• Management of neonatal infections…………………………………………………15 min
70
5.5.2.2. Aim
The aim of this session is to sensitize learners on the direct causes, signs and symptoms,
complications and management of neonatal infections.

On completion of this session, learners will be able
to: o Define neonatal infections
o Describe signs and symptoms of neonatal infections
o Describe the management of neonatal infections

A) Definition: Neonatal Infection is the invasion of the body by organisms such as bacteria,
viruses, fungi, spirochetes and protozoa.
NB: Immature systems make newborn infants susceptible to infection

Classification of infections;
Common minor infections
• conjunctivitis (Chlamydia, gonococcus, staphylococcus); Gonococcal conjunctivitis can
cause blindness
• umbilical cord sepsis, (E-coli, staphylococcus aureus, Clostridium tetani)
• skin infection (bullous impetigo, monilia rash)
• Oral thrush
71
Major infections and their management
DIAGNOSIS SIGNS/SYMPTOMS MANAGEMENT

Septicaemia – infection of lethargy, poor feeding Collect blood culture, while
blood stream or sucking, abdominal waiting for culture results, first
distension and vomiting, choice antibiotic combination is:
pallor, jaundice, purpura,
apnoea, hypothermia, oedema • Benzyl penicillin 50,000
of the sclerema units/kg
• Gentamycin 5mg/kg or
cloxacillin 50mg/kg
• Amikacin 5mg/kg
Second choice of antibiotics:
• Cefotaxime 50mg/kg or
ceftriaxone 50mg/kg
Pneumonia is an -Tachypnoea • Chest X-ray - will show

inflammation of lower the typical features of
respiratory tract including -Cyanosis pneumonia with areas of
the alveoli and bronchioles consolidation
can be caused by bacteria -Recession
or virus. -Granting General supportive care is
important
It can be acquired: There are usually also signs of
before delivery by septicemia Administer Oxygen if needed
inhaling infected liquor
Give intravenous or intramuscular
(chorioamnionitis)
antibiotics.
-during delivery (upper
-Cefotaxime 50mg/kg/dose IV or
airways organisms)
IM 12hourly
-after delivery (hospital
-Ceftriaxone 50mg/kg as a daily
acquired)
dose
-Benzyl penicillin 50,000 IU/kg
and an aminoglycoside are given.
Meningitis: is A typical presentation in -lumbar puncture
inflammation of membranes newborn
lining the brain and spinal The choice of antibiotics must
cord. • Irritability cover both gram negative bacilli
and the group B streptococcus.
• Convulsions
-Cefotaxime 50mg/kg/dose IV or
• Starring and clenching IM 12hourly
fists
-Ceftriaxone 50mg/kg as a daily
• Recurrent apnea or dose
cyanotic spells
-Phenobarbitone 20mg/kg IV/IM
• Hypo and hyperthermia then follow with 5mg/kg orally
daily until the infant is clinically
• Bulging fontanelle
well.
• Photophobia
Vomiting
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Necrotising enterocolitis • Signs of septicaemia Abdominal x-ray (will
(NEC) and shock reveal pneumatosis
intestinalis)
Definition: the necrosis • Abdominal distension and
of part or all of the small paralytic ileus • Keep nil per mouth
or large intestines. It is
usually found in 2 groups • Vomiting (often • Start intravenous infusion
of infants: bile stained) with human serum or
fresh frozen plasma
- terms infants who have • Blood in stool (occult)
had severe prenatal • • Insert an NG tube for free
hypoxia which has caused drainage
ischaemia and damage to Triple IV antibiotics
the gut (penicillin, gentamicin,
- Preterm infants who have metronidazole)
been infected in the
nursery. This form of
necrotizing enterocolitis
may occur in epidemics.
5.5.3. SESSION 3: MANAGING PREMATURE BABY

• Introduce session: Aim of the session………………………..……………………..…5 min
• Definition of premature baby…..……………………………………….……...........10 min
• Diagnosis of premature baby ……….………………………………….. …………10 min
• Management of premature baby …………………………………………………….25 min
5.5.3.2. Aim
The aim of this session is to sensitize participants on the direct causes, signs and symptoms, complica-
tions and management of premature baby.

• Define premature baby.
• Describe signs and symptoms of premature baby.
• Describe the management of premature baby.

A) DEFINATION: A baby born from 24 and before 37 weeks of gestation
DIAGNOSIS
Through:
• In history taking consider gestational age and baby’s weight
• Clinical features
B) MANAGEMENT
i) Keep warm, dry, and oil the baby
iii) Wrap with cotton wool
iv) Give Oxygen, when necessary
v) Feed with expressed breast milk or formula by mouth, use cup and spoon according to feeding
73
schedule
vi) If unable to swallow pass NGT for feeding
vii) Record feeds
viii) Counsel mother about the baby’s condition and care needed
ix) Reassure and support
x) If necessary refer and accompany the baby
C) COMPLICATIONS
• Respiratory distress
• Hypothermia
• Hypoglycemia
• Neonatal sepsis
D) Respiratory distress
Definition: A baby who presents with 2 or more of the following signs; tachypnea, sternal
recession, central cyanosis, grunting respirations, flarring, hypercapnia, respiratory or mixed
acidosis, hypoten-sion and shock.
Diagnosis
Lab investigations • Blood gases
• Chest X-ray
• FBC
• Blood culture
• U/E
E) Management
• O2 per either intubation or face mask
• Broad spectrum antibiotics while waiting for the results
• Give neonatalyte
• Record the following observations every hour and note any deterioration
i) Respiratory rate
ii) Presence or absence of recession and grunting
iii) Presence or absence of cyanosis
iv) Percentage of inspired oxygen if possible
v) Arterial oxygen saturation if possible
vi) Heart rate
vii) Both the skin(or axilla) and incubator temperature
• If possible transfer to a referral hospital
• Keep the infant pink in a head box oxygen or Continuous Positive Airways Pressure (CPAP)
via nasal prongs
• If the infant develops recurrent apnea or if CPAP fails to keep the infant pink then intubation
and ventilation are indicated.
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5.5.4. SESSION 4: MANAGING NEONATAL HYPOGLYCAEMIA
5.5.4.1. Session outline : 40 min
• Introduce session: Aim of the session………………………..…………………….…5 min
• Definition of neonatal hypoglycaemia...……………………………………...........10 min
• Diagnosis of neonatal hypoglycaemia ………………………………….. ………..10 min
• Management of neonatal hypoglycaemia …..………………………………………15 min
5.5.4.2. Aim
The aim of this session is to sensitize participants on the direct causes, signs and symptoms,
complications and management of neonatal hypoglycaemia.

On completion of this session, learners will be able to:
• Define neonatal hypoglycaemia.
• Describe signs and symptoms of neonatal hypoglycaemia.
• Describe the management of neonatal hypoglycaemia.

Definition: blood sugar < 2.5 mmol/l in the neonate in the first days of
life Diagnosis:
Signs and symptoms:
• Lethargy
• Poor feeding
• Weak cry
• Apnea
• Cyanosis
• Absence of moro reflex
• High pitched cry
• Fixed stare and fisting
• Abnormal eye movements or convulsions
Investigations:
• Random blood
sugar Management:
• Start IV line
• Give a bolus of 2ml/kg body weight of 10% dextrose slowly over 5 minutes.
• If IV line cannot be established quickly, give 2ml/kg body weight of 10% glucose by NG
tube. Maintenance
75
Table: Total daily feed and fluid volumes for babies from birth
Days of life 1 2 3 4 5 6 7+
Ml/kg body weight of feeds and /or fluid 60 80 100 120 140 150 160+
i) Measure blood glucose every 30 minutes after the bolus, then every three hours.
ii) If blood glucose is less than 1.5mmol/l, repeat the bolus of glucose and continue with the infusion.
iii) If blood glucose is less than 2mmol/l but it’s a least 1.5mmol/l, continue with the infusion and
repeat blood glucose every three hours until the reading is more than 2 mmol/l on two
consecutive measurements.
iv) Once the blood sugar is 2mmol/l or more for two consecutive measurements follow instructions
for frequency of blood glucose measurement after the blood glucose gets back to normal.
v) Allow breastfeeding, if baby cannot be breastfed, give expressed breast milk or formula
vi) As the baby’s ability to feed improves tamper glucose infusion and increase oral feeding
Blood glucose less than 2 mmol/l but at least 1.1mmol/l

• Allow breastfeeding, if baby cannot be breastfed, give expressed breast milk or formula
• Measure blood glucose in three hours or before the next feed,
• If blood glucose is 1.1mmol/l or less, treat as discussed above (i-vi)
• if blood glucose is less than 2 mmol/l but at least 1.1mmol/l, increase frequency of breastfeeding
• Once the blood sugar is 2mmol/l or more for two consecutive measurements follow instructions for
• frequency of blood glucose measurement after the blood glucose gets back to normal
Frequency of blood glucose measurement after blood glucose goes back to normal
• If baby is receiving IV fluids, measure every 12 hours, if blood glucose is less than 2mmol/l,
treat as above
• If baby is no longer on IV fluids, measure every 12 hours for 24 hours
• if blood glucose is less than 2mmol/l, treat as above if blood glucose remains normal,
discontinue measurements.
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MODULE 6. SPECIAL PROCEDURES
6.1. Bimanual compression of the
Uterus 6.2. Manual removal of the
placenta 6.3. Vacuum extraction
6.4. Repair of episiotomy and perineal tears
6.5. Caesarean Section
6.1. BIMANUAL COMPRESSION OF THE UTERUS

• Wear high level disinfected or sterile gloves, insert the hand into the vagina and remove any blood
clots from the lower part of the uterus or cervix.
• Form a fist and place the fist into the anterior fornix and apply pressure against the anterior wall
of the uterus with the other hand press deeply into the abdomen behind the uterus, applying
pressure against the posterior wall of the uterus.
• Maintain compression until bleeding is controlled and uterus contracts.
6.2. MANUAL REMOVAL OF THE PLACENTA

1. Put up oxytocin drip 40 Units in Normal saline or Ringers lactate
2. Give prophylactic antibiotics: Ampicillin2gm IV and metronidazole 500mg IV
3. The patient is sedated with 5-10 mg of diazepam plus 50 mg of pethidine given separately
intrave-nously slowly for 2 - 3 minutes. Oxygen should be within reach.
4. The person to perform the procedure must scrub the hands and arms up to the elbows and put on
sterile gloves. It is advisable to use the long gloves reaching the elbows to avoid contact with the
patients’ blood.
5. Using the sponge holding forceps and swabs or cotton soaked in antiseptic
solution, the vulva and the surrounding area are aseptically prepared.
6. With the left hand providing pressure on the uterine fundus through the
abdominal wall downwards the right hand is made a funnel shape and is
gently inserted into the vagina and through the open cervical canal into
the urine cavity.
7. Using the tip of the fingers the placental margin is located. The separation is
achieved through sideway slicing movements of the tip of the fingers
starting from the margin.
8. The placenta can be left to slip off past the hand into the vagina or the
hand can be removed grasping the whole completely separated placenta.
9. The uterine cavity is explored for:
• any abnormality
• any evidence of uterine rupture
• any remains of the placental tissue and membrane
8. Quick examination of the placenta for missing lobes
9. Repair any tear, lacerations and episiotomy
10. Patient must be monitored closely.
77
6.3. VACCUUM EXTRACTION
1) Careful evaluation and assessment of the patient is the key to successful vacuum
extraction. Critical review of the indication and accurate assessment of the appropriate
conditions are important and necessary.
2) The patient is placed in lithotomy position and external genitalia and surrounding areas are
cleaned with antiseptic solution. The operator must wear sterile gloves.
3) A final vaginal examination before application of the ventouse is mandatory.
4) The suction cup is connected to the vacuum extractor with rubber tubing.
5) The connecting tube must be long enough to avoid contamination of the operating area.
6) The ventouse is inserted into the vagina obliquely to avoid bruising the vaginal wall and the
urethra and is fitted onto the vertex. The index and middle fingers are passed around the
suction cup to ascertain that no soft tissues of the birth canal have been included.
7) If episiotomy is planned, it should be done prior to application of the ventouse. Infiltration of
the perineum with Lignocaine is a requirement.
8) Controlled negative pressure (of up to 0.7 - 0.8kg per sq. cm) is developed over a period of about
4 minutes.
9) During uterine contraction the parturient is encouraged to bear down and traction in the
direction of delivery axis is applied. Avoid traction without uterine contraction.
10) Once the head is delivered, the pressure is gradually released and the delivery proceeds in
the normal manner.
11) Careful inspection of the birth canal must be done after the delivery of the placenta to
exclude possible lacerations.
N.B: Delivery by vacuum extraction should closely imitate the normal delivery process
maintaining the usual mechanism of labour. Never use the cup to actively rotate the baby’s head.
6.4. REPAIR OF EPISIOTOMY AND PERINEAL TEARS

Repair of Episiotomy and 1st and 2nd Degree Perineal Tears:
Episiotomy or perineotomy is not necessary in all deliveries. Careful and timely assessment and
performance of this whenever it is necessary is important as to avoid irregular tears which may
result in inappropriate repair and poor healing. Basic principles of repair are similar to those
described for 3rd degree perineal tears.
Techniques of Repair of 3rd degree Tear:

1. The patient should be in lithotomy position.
2. Aseptic preparation of the surgeon and the external genitalia should be performed as
described earlier.
3. Adequate infiltration of the operation area with local or regional anaesthetic is often achieved
with 10cc to 20cc of lignocaine or equivalent.
4. Identify the tissues involved:
• vaginal mucosa
• the superficial transverse perineal muscle
• external sphincter ani muscle
• the skin
78
5. Repair should strive to restore the anatomy of the perineum as much as possible to its
original status:
• first identify and secure the ends of the muscles involved and approximate them across.
• approximate subcutaneous tissue
• repair the vaginal wall
• repair the skin
6.5. CAESAREAN SECTION PROCEDURE 1.

Position of the Patient on the Operating Table
This sometimes new roman new roman may vary according to the condition of the patient. In patients
with compromised respiratory and cardiac systems slight reverse Trendelenburg position may be
preferred. Trendelenburg position could facilitate easy dislodging of a deeply engaged presenting part
during extraction of the baby. Prior to induction of anaesthesia and sometimes new roman new roman
even after, slight left-lateral tilting of the patient minimizes the pressure of the uterus on the vena
cava. However this is likely to be inconvenient to the surgeon.
2. Anaesthesia: The choice of anaesthesia is often dictated by:

• availability of anaesthetic facilities
• availability of anaesthetic skills
• the condition of the patient
If a doctor or nurse has to give any form of anaesthesia consultation and orientation from a skilled
anaesthetist is mandatory. Preferably each institution should have one of the personnel trained in
anaesthetic techniques to provide the service in an emergency.
• In patients who have been in prolonged and or obstructed labour, a final vaginal examination
is useful to assess any change in the progress of labour after previous examination particularly
if considerable time has elapsed. In elective C/S, this may not be necessary. A urinary catheter
is inserted to keep the bladder empty throughout the operation.
4. Aseptic preparation of the surgeon and assistants.

It is compulsory for all those directly participating in this operation to wear a cap and mask. They
must scrub their arms to the elbows with an antiseptic solution for at least five minutes and then
wear sterile gowns and cloves.
5. Treatment of anterior abdominal wall skin.

This can be achieved by use of savlon or hibitane followed by hibitane in spirit or iodine. Acetavlon
may also be used.
6. Abdominal Incision
a) Pfannenstiel Incision:
In elective Caesarean sections (ECS) and in emergency cases when spending 1-2 minutes extra
does not jeopardise the well being of the mother and or foetus, this incision must be encouraged. It
is not just aesthetically sound but healing is also better and more effective.
79
b) Subumbilical Median Incision:
In ultra emergency situations where every minute counts, this is the incision of choice. It is also a
suitable incision where other abdominal procedures and exploration are anticipated.
c) Paramedian Incision
This type of incision should be discouraged in obstetrics
7. Incision on the uterus:

Low segment transverse incision is recommended in all cases. In special conditions upper segment
longitudinal incision may be made (classical incision). Sometimes new roman new roman you can
make an inverted T-incision.
Before the opening of the uterus para-colic spaces on both sides are packed with wet large
abdominal packs to arrest the spread of amniotic fluid and blood in the abdominal cavity. The lower
uterine segment is exposed by careful dissection of the peritoneum overlying the lower uterine
segment and the bladder and deflexion of the latter downwards.
Opening of the uterus through the transverse incision can be achieved by:
making a small window incision sharply at the centre. The two index fingers are used to extend the
incision laterally through the window. This mode of opening of the uterus is recommended because
there is minimum bleeding and the separation of the muscles follows the structural arrangement of
uterine muscles in this area and so the healing is with minimum fibrosis.
• making a sharp window opening at the centre with a scalpel and sharp extension of the incision with
scissors making ellipsoid incision with both ends curving upwards at the angles. Proponents of this
approach argue that in this way a more regular cut is made and therefore better repair, and damage
to the uterine artery is avoided. In fact risk of cutting through uterine artery is more increased in this
approach than in blunt opening.
8. Delivery of the baby:

If membranes are intact, they must be ruptured before proceeding to deliver the baby.
Cephalic Presentation:
The surgeons hand on the caudal side of the patient is inserted through the incision and is slid
behind the head of the foetus. The head is then lifted up through the incision and outside. Sometimes
new roman new roman gentle fundal pressure may be necessary to achieve this.
Breech Presentation:
In complete and footling breech the feet are delivered through the incision first. The rest of the
delivery of the baby follows the basic rules in breech delivery i.e. avoid undue pressure on the foetal
abdomen; and traction pressure should be confined on the thighs and the sacrum. Delivery of the after
coming head is generally similar to that described under the vaginal breech delivery.
In frank breech the delivery of the baby is as described under partial breech extraction
80
Transverse Lie:
The basic principle here is to deliver first the foetal pole that is nearer to the incision. If there is arm
prolapse, no attempt should be made to return the prolapsed arm into the uterus by an assistant from
below. Since in such a case it is obvious that the head is the nearest pole to the incision, the arm will
automatically follow its delivery.
NB: Delivery of the breech in C/S is breech extraction
9. Delivery of the Placenta and Membranes:

After the delivery of the baby the bleeders in the uterine incision must be secured with
Green Armitages to avoid excessive blood loss.
Appropriate oxytocic is administered intravenously to the mother as the baby is delivered. This leads
to expeditious uterine contraction and placental separation. The placenta and membranes can be
delivered with gentle cord traction.
If there is abrupt excessive bleeding from the placental site after the delivery of the baby quick manual
removal of the placenta and membranes becomes necessary.
In all situations after the delivery of the placenta, digital revision of the uterine cavity is mandatory to
exclude:
• retained parts of the placenta and membranes
• uterine abnormality
10. Closure of Uterine Incision:

Close the myometrial layer using absorbable sutures e.g chromic catgut number 1 in either a continu-
ous or interlocking stitch. The latter is preferable if competent assistance to the surgeon is lacking.
The continuous stitch is generally quicker and should be used where there is good assistance to
main-tain the stitch constantly under tension.
Explore the abdominal cavity and posterior uterine wall including the adnexae to ascertain intactness of
the uterus and the absence of any abdominal and pelvic pathology. Remove the abdominal packs.
11. Closure of the abdominal wall:

The scrub nurse checks and accounts for all the instruments as before the operation started.
• Close the rectus sheath in a continuous fashion with appropriate suture material.
• If the subcutaneous fat is excessive it is generally advisable to approximate the adipose tissue with
interrupted stitches using catgut No. 0. This obliterates the dead spaces in the suture line and pre-
vents formation of haematomas, which often interfere with primary healing of the wound.
12. Closure of the skin:

Subcutaneous stitch: this should be the preferred approach unless the status of the abdominal wall or
the incision is unfavourable. Absorbable sutures (chromic catgut, dexon, vicryl) are appropriate. If
these are unavailable nylon suture can be used and removed on 6th/7th postoperative day. Silk sutures
may be used but it is difficult and painful to remove.
Interrupted Stitch:
81
If this has to be made, non-absorbable sutures are used and removed on the 6th/7th postoperative
day. They are painful to remove and leave ugly skin marks. At this point all the instruments are
accounted for once more.
The wound is appropriately dressed with sterile gauze and other supplementary. Pressure dressing is
sometimes new roman new roman necessary.
82
CP TASK SHEET/LEARNING GUIDE 11:
BIMANUAL COMPRESSION OF THE UTERUS
(To be used by the Learners for clinical practice)
LEARNING GUIDE FOR BIMANUAL COMPRESSION OF THE UTERUS

(Many of the following steps/tasks should be performed simultaneously.)
STEP/TASK
GETTING READY
1. Tell the woman (and her support person) what is going to be done, listen to her
and respond attentively to her questions and concerns.
2. Provide continual emotional support and reassurance, as feasible.
3. Put on personal protective barriers.

BIMANUAL COMPRESSION
1. Wash hands thoroughly with soap and water and dry with a clean, dry cloth or air dry.
2. Put high-level disinfected or sterile surgical gloves on both hands.
3. Clean the vulva and perineum with antiseptic solution.
4. Insert one hand into the vagina and form a fist.
5. Place the fist into the anterior vaginal fornix and apply pressure against the
anterior wall of the uterus.
6. Place the other hand on the abdomen behind the uterus.
7. Press the abdominal hand deeply into the abdomen and apply pressure against the
posterior wall of the uterus.
8. Maintain compression until bleeding is controlled and the uterus contracts.
POSTPROCEDURE TASKS
1. Immerse both gloved hands in 0.5% chlorine solution. Remove gloves by turning
them inside out.
l If disposing of gloves, place them in a leakproof container or plastic bag.
l If reusing surgical gloves, submerge them in 0.5% chlorine solution for 10 minutes
for decontamination.
3. Monitor vaginal bleeding and take the woman’s vital

signs: l Every 15 minutes for 1 hour
l Then every 30 minutes for 2 hours
4. Make sure that the uterus is firmly contracted.
83
CP CHECKLIST 11: BIMANUAL COMPRESSION OF THE UTERUS
(To be used by the Teacher/Facilitator for evaluation of the Learner’s skills)
Instructions for the Teacher/Facilitator:

Place a “T” in case box if step/task is performed satisfactorily, an “X” if it is not
performed satisfactorily, or N/O if not observed.
Satisfactory: Performs the step or task according to the standard procedure or guidelines
Unsatisfactory: Unable to perform the step or task according to the standard procedure or
guidelines
Not Observed: Step or task not performed by learner during evaluation by teacher
Date Observed ________________
Participant’s number 1 2 3 4
Participant’s initials
STEP/TASK
GETTING READY
1. Tell the woman (and her support person) what is going to be done,
listen to her and respond attentively to her questions and concerns.
SKILL/ACTIVITY PERFORMED SATISFACTORILY

BIMANUAL COMPRESSION
1. Wash hands thoroughly and put on high-level disinfected or
sterile surgical gloves.
3. Clean vulva and perineum with antiseptic solution.
4. Insert one hand into the vagina and form a fist.
5. Insert fist into anterior vaginal fornix and apply pressure against
the anterior wall of the uterus.
6. Place the other hand on the abdomen behind the uterus,
7. Press the hand deeply into the abdomen and apply pressure against
the posterior wall of the uterus.
84
8. Maintain compression until bleeding is controlled and the
uterus contracts.
POSTPROCEDURE TASKS
1. Immerse both gloved hands in 0.5% chlorine solution. Remove gloves by turning them
inside out.
 If disposing of gloves, place them in a leakproof container or plastic bag.
 If reusing surgical gloves, submerge them in 0.5% chlorine solution for 10 minutes
for decontamination
2. Wash hands thoroughly with soap and water and dry with a clean,
dry cloth or air dry.
3.Monitor vaginal bleeding and take the woman’s vital signs:

 Every 15 minutes for 1 hour,
 Then every 30 minutes for 2 hours
4. Make sure that the uterus is firmly contracted.
Learner’s name Teacher/Facilitator’s comments
85
INSTRUCTIONS FOR SKILLS PRACTICE SESSION 11:
BIMANUAL COMPRESSION OF THE UTERUS
PURPOSE INSTRUCTIONS RESOURCES

The purpose of this activity This activity should be The following equipment or
is to enable learners conducted in a simulated setting, representations thereof:
to practice bimanual using the appropriate models. l Childbirth simulator
compression of the uterus l Delivery instrument kit
and achieve competency in l High-level disinfected or
the skills required. sterile surgical gloves
l Personal protective barriers
Learners should review Learning Learning Guide 11: Bimanual

Guide 11. before beginning the Compression of the Uterus
activity.
The teacher should demonstrate Learning Guide 11: Bimanual

the steps/tasks in the procedure Compression of the Uterus
of bimanual compression of
the uterus for learners. Under
the guidance of the teacher,
learners should then work in
pairs to practice the steps/
tasks and observe each other’s
performance, using Learning
Guide 11.
Learners should be able to Checklist 11: Bimanual

perform the steps/tasks in Compression of the Uterus
Learning Guide 4.1 before skill
competency is assessed by the
teacher in the simulated setting,
using Checklist 11 to assess each
other’s performance.
Finally, following supervised Checklist 11: Bimanual

practice at a clinical site, the Compression of the Uterus
teacher should assess the skill
competency of each learner,
using Checklist 11.1
(Footnotes)
1 If patients are not available at clinical sites for learners to practice the procedure of bimanual compression of the uterus,
the skills should be taught, practiced and assessed in a simulated setting.
86
CP TASK SHEET/LEARNING GUIDE 12: BREECH DELIVERY
(To be used by Learners for Clinical Practice)
LEARNING GUIDE FOR BREECH DELIVERY

STEP/TASK
GETTING READY
1. Prepare the necessary equipment.
2. Tell the woman (and her support person) what is going to be done, listen to her
and respond attentively to her questions and concerns.
4. Review to ensure that the following conditions for breech delivery are present:
l Complete or frank breech
l Adequate clinical pelvimetry
l Fetus is not too large
l No previous cesarean section for cephalopelvic disproportion
lFlexed head
PREPROCEDURE TASKS
1. Wash hands thoroughly with soap and water and dry with a clean, dry cloth or
air dry.
3. Clean the vulva with antiseptic solution.
4. Catheterize the bladder, if necessary.
BREECH DELIVERY
Delivery of the Buttocks and Legs
1. When the buttocks have entered the vagina and the cervix is fully dilated, tell the
woman she can bear down with contractions.
2. If the perineum is very tight, perform an episiotomy.
3. Let the buttocks deliver until the lower back and then the shoulder blades are seen.
4. Gently hold the buttocks in one hand, but do not pull.
5. If the legs do not deliver spontaneously, deliver one leg at a time:

l Push behind the knee to bend the leg. Grasp
l the ankle and deliver the foot and leg.
l Repeat for the other leg.
87
STEP/TASK
Hold the baby by the hips, but do not pull.
Delivery of the Arms
6. If the arms are felt on the chest, allow them to disengage spontaneously:
l After spontaneous delivery of the first arm, lift the buttocks toward the mother’s abdomen
to enable the second arm to deliver spontaneously.
l If the arm does not deliver spontaneously, place one or two fingers in the
elbow and bend the arm, bringing the hand down over the baby’s face.
8. If the arms are stretched above the head or folded around the neck, use
Lovset’s maneuver:
l Hold the baby by the hips and turn half a circle, keeping the back uppermost.
l Apply downward traction at the same time so that the posterior arm becomes anterior, and
deliver the arm under the pubic arch by placing two fingers on the upper part of the arm.
l Draw the arm down over the chest as the elbow is flexed, with the hand sweeping over the face.
l To deliver the second arm, turn the baby back half a circle while keeping the
back uppermost and applying downward traction to deliver the second arm in
the same way under the pubic arch.
9. If the baby’s body cannot be turned to deliver the arm that is anterior first, deliver
the arm that is posterior:
l Hold and lift the baby up by the ankles.
l Move the baby’s chest toward the woman’s inner leg to deliver the posterior
l shoulder. Deliver the arm and hand.
l Lay the baby down by the ankles to deliver the anterior shoulder.
l Deliver the arm and hand.
Delivery of the Head
10. Deliver the head by the Mauriceau Smellie Veit maneuver:

l Lay baby face down with the length of its body over your hand and arm.
l Place first and third fingers of this hand on the baby’s cheekbones.
l Place second finger in the baby’s mouth to pull the jaw down and flex the
l head. Use the other hand to grasp the baby’s shoulders.
l With two fingers of this hand, gently flex the baby’s head toward the chest.
l At the same time apply downward pressure on the jaw to bring the baby’s head down until
the hairline is visible.
l Pull gently to deliver the head.
l Ask an assistant to push gently above the mother’s pubic bone as the head delivers.
Raise the baby, still astride the arm, until the mouth and nose are free.
l
11. Check the birth canal for tears following delivery, and repair if necessary.
12. Repair the episiotomy, if one was performed.
13. Provide immediate postpartum and newborn care, as required.
POSTPROCEDURE TASKS
1. Before removing gloves, dispose of waste materials in a leakproof container

or plastic bag.
88
STEP/TASK
2. Place all instruments in 0.5% chlorine solution for 10 minutes for decontamination.
3. Immerse both gloved hands in 0.5% chlorine solution. Remove gloves by turning
them inside out.
l If reusing surgical gloves, submerge them in 0.5% chlorine solution for
10 minutes for decontamination.
4. Wash hands thoroughly with soap and water and dry with a clean, dry cloth or
air dry.
CP CHECKLIST 12: BREECH DELIVERY

(To be used by the Teacher/Facilitator for evaluation of the Learner’s skills.)
Many of the following steps/tasks should be performed simultaneously.)
Place a “T” in case box if step/task is performed satisfactorily, an “X” if it is not

performed satisfactorily, or N/O if not observed.
guidelines
Date Observed _____________
STEP/TASK CASES
GETTING READY
2. Tell the woman (and her support person) what is going to be done,
listen to her and respond attentively to her questions and concerns.
4. Ensure that the conditions for breech delivery are present.
89
PREPROCEDURE TASKS

2. Clean the vulva with antiseptic solution.
3. Catheterize the bladder, if necessary.
BREECH DELIVERY
Delivery of the Buttocks and Legs
1. When the buttocks have entered the vagina and the cervix is fully
dilated, tell the woman she can bear down with contractions.
2. Perform an episiotomy, if necessary.
3. Let the buttocks deliver until the lower back and shoulder blades
are seen.
4. Gently hold the buttocks in one hand.
5. If the legs do not deliver spontaneously, deliver one leg at a time.
6. Hold the baby by the hips.
Delivery of the Arms
7. If the arms are felt on the chest, allow them to disengage

spontaneously.
8. If the arms are stretched above the head or folded around the neck,
use Lovset’s maneuver.
9. If the baby’s body cannot be turned to deliver the arm that is
anterior first, deliver the arm that is posterior.
Delivery of the Head
10. Deliver the head using the Mauriceau Smellie Veit maneuver.
11. Following delivery, check the birth canal for tears and repairs,
if necessary. Repair the episiotomy, if one was performed.
90
12. Provide immediate postpartum and newborn care, as required.
POSTPROCEDURE TASKS
1. Before removing gloves, dispose of waste materials in a leakproof

container or plastic bag.
2. Place all instruments in 0.5% chlorine solution for decontamination.
3. Remove gloves and discard them in a leakproof container or plastic bag if disposing
of or decontaminate them in 0.5% chlorine solution if reusing.
4. Wash hands thoroughly.

1
91
BREECH DELIVERY
The purpose of this activity This activity should be conducted The following equipment or
is to enable learners to in a simulated setting, using the representations thereof:
practice breech delivery and appropriate models. l Childbirth simulator
achieve competence in the l High-level disinfected or
procedure. sterile surgical gloves
l
Learners should review Learning Learning Guide 12: Breech
Guide 12. before beginning the Delivery
activity.
The teacher should demonstrate Learning Guide 12: Breech

the steps/tasks in the procedure Delivery
of breech delivery for learners.
Under the guidance of the teacher,
learners should then work in pairs
to practice the steps/tasks and
observe each other’s performance,
using Learning Guide 12.
Learners should be able to perform Checklist 12: Breech Delivery

the steps/tasks in Learning Guide
7.1 before skill competency is
assessed by the teacher in the
simulated setting, using Checklist
12.
Finally, following supervised Checklist 12: Breech Delivery

practice at a clinical site, the
competency of each learner, using
Checklist 12.1
(Footnotes)
1. If patients are not available at clinical sites for learners to practice breech delivery, the skills should be taught, practiced
and assessed in a simulated setting.
92
CP TASK SHEET/LEARNING GUIDE 13: EPISIOTOMY AND REPAIR
(To be used by the Learners for Clinical Practice)
LEARNING GUIDE FOR EPISIOTOMY AND REPAIR (Many of

the following steps/tasks should be performed simultaneously.)
STEP/TASK
GETTING READY
2. Tell the woman (and her support person) what is going to be done, listen to her and respond
attentively to her questions and concerns.
4. Ask about allergies to antiseptics and anesthetics.
5. Put on personal protective barriers ( protective clothing and gloves).
ADMINISTERING LOCAL ANESTHETIC

3. Clean the perineum with antiseptic solution.
4. Draw 10 mL of 0.5% lignocaine into a syringe.
5. Place two fingers into the vagina along the proposed incision line.
6. Insert the needle beneath the skin for 4–5 cm following the same line and aspirate by drawing
the plunger back slightly to make certain the needle is not penetrating a blood vessel.
7. Inject the lignocaine solution into the vaginal mucosa, beneath the skin of the perineum and into the
perineal muscle.
8. Wait 2 minutes and then pinch the incision site with forceps. (If the woman feels the pinch, wait 2
more minutes and then retest.)
MAKING THE EPISIOTOMY
1. Wait to perform episiotomy until: l

The perineum is thinned out.
l3–4 cm of the baby’s head is visible during a contraction.
2. Insert two fingers into the vagina, palmar side downward, between the baby’s head and the perineum.
3. Insert the open blade of the scissors between the perineum and the two fingers.
4. Make a single cut 3–4 cm long in a mediolateral direction (45º angle to the midline toward a point
midway between the ischial tuberosity and the anus).
5. If delivery of the head does not follow immediately, apply pressure to the episiotomy site
between contractions, using a piece of gauze, to minimize bleeding.
6. Control delivery of the head to avoid extension of the episiotomy.
93
STEP/TASK
REPAIRING THE EPISIOTOMY

1. Ask the woman to position her buttocks toward the lower end of the bed or table (use stirrups
if available).
2. Ask an assistant to direct a strong light onto the woman’s perineum.
3. Clean the woman’s perineum with antiseptic solution.
4. If it is necessary to repeat local anesthetic, draw 10 mL of 0.5% lignocaine into a syringe.
5. Insert the needle along one side of the vaginal incision and inject the lignocaine solution while
slowly withdrawing the needle.
6. Repeat on the other side of the vaginal incision and on each side of the perineal incision.
7. Wait 2 minutes to allow the lignocaine solution to take effect.
8. Using 2/0 chromic catgut, insert the suture needle just above (1 cm) the vaginal incision.
9. Use a continuous suture from the apex downward to repair the vaginal incision.
10. Continue the suture to the level of the vaginal opening.
11. At the opening of the vagina, bring together the cut edges.
12. Bring the needle under the vaginal opening and out through the incision and tie.
13. Use interrupted sutures to repair the perineal muscle, working from the top of the perineal
incision downward.
14. Use interrupted or subcuticular sutures to bring the skin edges together.
15. Place a clean pad on the woman’s perineum.
POSTPROCEDURE TASKS
1. Before removing gloves, dispose of waste materials in a leakproof container or plastic bag.
3. Decontaminate or dispose of syringe and needle:

l If reusing needle or syringe, fill syringe (with needle attached) with 0.5% chlorine solution and
submerge in solution for 10 minutes for decontamination.
lIf disposing of needle and syringe, flush needle and syringe with 0.5% chlorine solution three times
new roman new roman, then place in a puncture-proof container.
4. Immerse both gloved hands in 0.5% chlorine solution. Remove gloves by turning them inside out.
lIf reusing surgical gloves, submerge them in 0.5% chlorine solution for 10 minutes for
decontamination.
94
STEP/TASK
6. Record the procedure on woman’s record.
CP CHECKLIST 13: EPISIOTOMY AND REPAIR

(To be used by the Teacher/Facilitator for evaluation of the Learner’s skills.
Instructions for Trainers/facilitators:

Place a “T” in case box if step/task is performed satisfactorily, an “X” if it is not performed satisfactorily, or N/O if
not observed.
Unsatisfactory: Unable to perform the step or task according to the standard procedure or guidelines
STEP/TASK
GETTING READY
2. Tell the woman (and her support person) what is going to be done and encourage
them to ask questions.
1. Wash hands thoroughly and put on high-level disinfected or sterile surgical gloves.
3. Administer local anesthetic.
4. Perform episiotomy when perineum is thinned out and baby’s head is visible during
a contraction.
5. Insert two fingers into the vagina between the baby’s head and the perineum.
6. Insert the open blade of the scissors between the perineum and the fingers. Make
a single cut in a mediolateral direction.
7. If delivery of the head does not follow immediately, apply pressure to the
episiotomy site between contractions.
95
STEP/TASK

2. Repeat local anesthetic, if necessary.
4. At the vaginal opening, bring the cut edges together.
6. Use interrupted sutures to repair the perineal muscle, working from the top of the
perineal incision downward and to bring the skin edges together.
POSTPROCEDURE TASKS
1. Before removing gloves, dispose of waste materials in a leakproof container or
plastic bag.
3. If reusing needle or syringe, fill syringe (with needle attached) with 0.5%
chlorine solution and submerge in solution for decontamination. If disposing of
needle and syringe, place in puncture-proof container.
4. Remove gloves and discard them in a leakproof container or plastic bag if disposing
of or decontaminate them in 0.5% chlorine solution if reusing.
6. Record procedure on woman’s record.

1
96
CP TASK SHEET/LEARNING GUIDE 13: EPISIOTOMY AND REPAIR
(To be used by the Learners for Clinical Practice)

STEP/TASK
GETTING READY
2. Tell the woman (and her support person) what is going to be done, listen to her and respond
5. Put on personal protective barriers ( protective clothing and gloves).
ADMINISTERING LOCAL ANESTHETIC

4. Draw 10 mL of 0.5% lignocaine into a syringe.
5. Place two fingers into the vagina along the proposed incision line.
6. Insert the needle beneath the skin for 4–5 cm following the same line and aspirate by drawing
the plunger back slightly to make certain the needle is not penetrating a blood vessel.
7. Inject the lignocaine solution into the vaginal mucosa, beneath the skin of the perineum and into the
perineal muscle.
8. Wait 2 minutes and then pinch the incision site with forceps. (If the woman feels the pinch, wait 2
1. Wait to perform episiotomy until: l
The perineum is thinned out.
l3–4 cm of the baby’s head is visible during a contraction.
2. Insert two fingers into the vagina, palmar side downward, between the baby’s head and the perineum.
3. Insert the open blade of the scissors between the perineum and the two fingers.
4. Make a single cut 3–4 cm long in a mediolateral direction (45º angle to the midline toward a point
midway between the ischial tuberosity and the anus).
5. If delivery of the head does not follow immediately, apply pressure to the episiotomy site
between contractions, using a piece of gauze, to minimize bleeding.

1. Ask the woman to position her buttocks toward the lower end of the bed or table (use stirrups
if available).
2. Ask an assistant to direct a strong light onto the woman’s perineum.
4. If it is necessary to repeat local anesthetic, draw 10 mL of 0.5% lignocaine into a syringe.
5. Insert the needle along one side of the vaginal incision and inject the lignocaine solution while
slowly withdrawing the needle.
6. Repeat on the other side of the vaginal incision and on each side of the perineal incision.
7. Wait 2 minutes to allow the lignocaine solution to take effect.
8. Using 2/0 chromic catgut, insert the suture needle just above (1 cm) the vaginal incision.
10. Continue the suture to the level of the vaginal opening.
11. At the opening of the vagina, bring together the cut edges.
97
STEP/TASK
13. Use interrupted sutures to repair the perineal muscle, working from the top of the perineal
incision downward.
14. Use interrupted or subcuticular sutures to bring the skin edges together.
POSTPROCEDURE TASKS
1. Before removing gloves, dispose of waste materials in a leakproof container or plastic bag.
3. Decontaminate or dispose of syringe and needle:
l If reusing needle or syringe, fill syringe (with needle attached) with 0.5% chlorine solution
and submerge in solution for 10 minutes for decontamination.
l If disposing of needle and syringe, flush needle and syringe with 0.5% chlorine solution three
times new roman new roman, then place in a puncture-proof container.
6. Record the procedure on woman’s record.
CP CHECKLIST 13: EPISIOTOMY AND REPAIR

(To be used by the Teacher/Facilitator for evaluation of the Learner’s skills.
Instructions for Trainers/facilitators:

Place a “T” in case box if step/task is performed satisfactorily, an “X” if it is not performed satisfactorily, or N/O if
not observed.
Unsatisfactory: Unable to perform the step or task according to the standard procedure or guidelines
STEP/TASK
GETTING READY
2. Tell the woman (and her support person) what is going to be done and
encourage them to ask questions.
98
STEP/TASK
1. Wash hands thoroughly and put on high-level disinfected or sterile surgical gloves.
4. Perform episiotomy when perineum is thinned out and baby’s head is visible during
a contraction.
5. Insert two fingers into the vagina between the baby’s head and the perineum.
6. Insert the open blade of the scissors between the perineum and the fingers. Make
a single cut in a mediolateral direction.
7. If delivery of the head does not follow immediately, apply pressure to the
episiotomy site between contractions.
2. Repeat local anesthetic, if necessary.

4. At the vaginal opening, bring the cut edges together.
6. Use interrupted sutures to repair the perineal muscle, working from the top of the
perineal incision downward and to bring the skin edges together.
POSTPROCEDURE TASKS
1. Before removing gloves, dispose of waste materials in a leakproof container or
plastic bag.
3. If reusing needle or syringe, fill syringe (with needle attached) with 0.5%
chlorine solution and submerge in solution for decontamination. If disposing of
needle and syringe, place in puncture-proof container.
4. Remove gloves and discard them in a leakproof container or plastic bag if
disposing of or decontaminate them in 0.5% chlorine solution if reusing.
6. Record procedure on woman’s record.

1
99
EPISIOTOMY AND REPAIR

is to enable learners in a simulated setting, using the representations thereof:
to practice episiotomy appropriate models. lPelvic model or “foam
and repair and achieve block” that would enable

competency in the skills episiotomy and repair to be
required. performed
lHigh-level disinfected or
sterile surgical gloves

l Examination light
l Local anesthetic
l Needle and syringe
l Suture materials
Learners should review Learning Learning Guide 13:

Guide 13. before beginning the Episiotomy and Repair.
activity.
The teacher should demonstrate Learning Guide 13:

the steps/tasks in the procedure of Episiotomy and Repair
episiotomy and repair for learners.
Under the guidance of the trainer,
learners should then work in pairs
to practice the steps/tasks and
observe each other’s performance,
using Learning Guide 13.
Learners should be able to perform Checklist 13: Episiotomy and

the steps/tasks in Learning Guide Repair
7.2 before skill competency is
assessed by the teacher in the
simulated setting, using Checklist
13.
Finally, following supervised Checklist 13: Episiotomy and

practice at a clinical site, the Repair
Checklist 13.1
(Footnotes)
1. If patients are not available at clinical sites for learners to practice the procedure of episiotomy and repair in the clinical
area, the skills should be taught, practiced and assessed in a simulated setting.
100
CP TASK SHEET/LEARNING GUIDE 14:
REPAIR OF THIRD AND FOURTH DEGREE OF PERINEAL
TEARS (To be used by Learners for Clinical Practice)
LEARNING GUIDE FOR REPAIR OF THIRD AND

FOURTH DEGREE OF PERINEAL TEARS

STEP/TASK
GETTING READY

2. Tell the woman (and support person) what is going to be done, listen to her and respond
5. Have the woman empty her bladder or insert a catheter, if necessary.
REPAIR OF THIRD AND FOURTH DEGREE TEARS

3. To see if the anal sphincter is torn:
l Place a gloved finger in the anus and lift slightly. l
Identify the sphincter or lack of it.
l Feel the surface of the rectum and look carefully for a tear.
6. Put another pair of high-level disinfected or sterile surgical gloves on both hands.
7. Apply antiseptic solution to the areas around the tear and remove any fecal material, if present.
Administering Local Anesthetic

8. Draw 10 mL of 0.5% lignocaine solution into a syringe.
9. Insert the needle beneath the vaginal mucosa and aspirate by drawing the plunger back slightly to make
certain the needle is not penetrating a blood vessel.
10. Inject the lignocaine solution into the vaginal mucosa, beneath the skin of the perineum and deep into the
perineal muscle.
11. Wait 2 minutes and then pinch the cervix with the forceps. (If the woman feels the pinch, wait 2
Repairing the Tear

12. Bring the rectal mucosa together using interrupted sutures 0.5 cm apart:
lPlace the suture through the muscularis, not all the way through the mucosa.
Cover the muscularis layer by bringing together the fascial layer with interrupted sutures.
l l
Apply antiseptic solution to the area frequently while working.
13. If the sphincter is torn:
lGrasp each end of the sphincter with an Allis clamp.
lRepair the sphincter with two or three interrupted sutures.
14. Apply antiseptic solution to the area again.
15. Examine the anus with a gloved finger to ensure correct repair of the rectum and sphincter.
101
LEARNING GUIDE FOR REPAIR OF THIRD AND
FOURTH DEGREE OF PERINEAL TEARS

STEP/TASK
lIf reusing surgical gloves, submerge them in 0.5% chlorine solution for 10 minutes for
decontamination.
18. Put another pair of high-level disinfected surgical gloves on both hands.
19. Repair the vaginal mucosa, perineal muscles and skin
POSTPROCEDURE TASKS
1. Before removing gloves, dispose of waste materials in a leakproof container or plastic
bag.
3. Decontaminate or dispose of needle or syringe:
l If reusing needle or syringe, fill syringe (with needle attached) with 0.5% chlorine
solution and submerge in solution for 10 minutes for decontamination.

lIf disposing of needle and syringe, flush the needle and syringe with 0.5% chlorine
solution three times new roman new roman, then place in a puncture-proof container. 4.
Immerse both gloved hands in 0.5% chlorine solution. Remove gloves by turning them
inside out.
CP CHECKLIST 14: REPAIR OF THIRD AND FOURTH DEGREE

OF PERINEAL TEARS
(To be used by the Teacher/Facilitator for evaluation of the Learner’s skills.)
Instructions for Trainers/Facilitators:

Place a “ü” in case box if task/activity is performed satisfactorily, an “X” if it is not performed
satisfactorily, or N/O if not observed.
guidelines
Not Observed: Step, task or skill not performed by learner during evaluation by teacher
Date Observed ________________
102
STEP/TASK
GETTING READY
2. Tell the woman what is going to be done, listen to her and
respond attentively to her questions and concerns.
5. Have the woman empty her bladder or insert a catheter.
REPAIR OF THIRD AND FOURTH DEGREE TEARS

2. Check to see if the anal sphincter is torn.
3. Remove gloves and discard them in a leakproof container or plastic

bag if disposing of or decontaminate them in 0.5% chlorine solution
if reusing.
5. Put on another pair of high-level disinfected or sterile surgical gloves.
6. Apply antiseptic solution to the areas around the tear and remove any
fecal material.
8. Repair the rectal mucosa and the sphincter if torn using

interrupted sutures.
9. Apply antiseptic solution to the area again.
10. Ensure correct repair of the rectum and sphincter.
11. Remove gloves and discard them in a leakproof container or plastic bag or
decontaminate them in 0.5% chlorine solution if reusing.
12. Put on another pair of high-level disinfected or sterile surgical gloves.
13. Repair the vaginal mucosa, perineal muscles and skin.
103
POSTPROCEDURE TASKS
1. Before removing gloves, dispose of waste materials in a leakproof

container or plastic bag.
3. If reusing needle or syringe, fill syringe (with needle attached) with

0.5% chlorine solution and submerge in solution for decontamination. If
disposing of needle and syringe, place in puncture-proof container.
4. Remove gloves and discard them in a leakproof container or plastic bag if disposing of
or decontaminate them in 0.5% chlorine solution if reusing.

1
104
REPAIR OF THIRD AND FOURTH DEGREE OF PERINEAL TEARS
is to enable learners to in a simulated setting, using the representations thereof:
practice repair of third and appropriate models. lFoam block to simulate a
fourth degree perineal tears vagina

and achieve competency in l High-level disinfected or
the skills required. sterile surgical gloves
l Examination light
l Local anesthetic
l Needle and syringe
l Suture materials
Learners should review Learning Guide Learning Guide 14: Repair

14. before beginning the activity. Third and Fourth Degree
Perinea Tears
The teacher should demonstrate the Learning Guide 14: Repair
steps/tasks in the procedure of repair of Third and Fourth Degree
of third and fourth degree perinea tears
for learners. Under the guidance of the Perinea Tears
trainer, learners should then work in pairs
to practice the steps/tasks and observe
each other’s performance, using Learning
Guide 14.
Learners should be able to Checklist for Repair of Third

perform the steps/tasks in and Fourth Degree Perinea
Learning Guide 14 before skill Tears
competency is assessed by the
teacher in the simulated setting,
using the Checklist for Repair of
Third and Fourth Degree Perinea
Tears.
Finally, following supervised Checklist 14: Repair of Third

practice at a clinical site, the and Fourth Degree Perinea
teacher should assess the skill Tears
Checklist 14.1
(Footnotes)
1 If patients are not available at clinical sites for learners to practice the procedure of repair of third and fourth degree
perineal tears, the skills should be taught, practiced and assessed in a simulated setting.
105
REFERENCE MATERIALS
• Ministry of Health of Botswana: Guidelines for Antenatal Care and the Management of
Obstetric Emergencies and PMTCT of HIV.
• WHO: Managing Complications in Pregnancy and Childbirth: A guide for midwives, nurses
and doctors.
• WHO: Managing Newborn Problems: A guide for doctors, nurses and midwives.
• WHO: Pregnancy, Childbirth, Postpartum and newborn Care (PCPNC) : A Guide for
Essential Practice.
106
107
Produced by:
Ministry of Health
Department of Public Health
Sexual & Reproductive Health Division
Private Bag 00269, Gaborone
Tel: +267 3170585 Fax: +267 3902092
Design and layout by: Quick Swift Tel: 3165323
108

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Emergency Obsteric and Newborn care

5.2. MODULE 2: MANAGING PROLONGED, OBSTRUCTED LABOUR AND

5.3. MODULE 3: MANAGING HYPERTENSIVE DISORDERS IN

5.5. MODULE 5: MANAGING OF THE NEWBORN COMPLICATIONS

6.2. REFERANCE MATERIALS

Setting standards for emergency obstetric and newborn care

b) Signal Functions of Comprehensive EmONC

2. JUSTICICATION: THE BOTSWANA SITUATION

3.1. The purpose of this manual:

3.2. Content of the Training Manual

3.3. Structure of the Modules

Module 1: Managing Obstetric Haemorrhage, Abortion and Anaemia

Module 3: Managing Hypertensive Disorders in Pregnancy

Module 4: Managing Puerperal Sepsis

Module 5: Managing of the Newborn Complications (Infections, Asphyxia, Prematurity).

4.2. Order of the sessions

4.3. Organization of the individual sessions

4.4. Teaching methods

4.5. Clinical practice information

SUMMARY OF THE MODULE

5.1.1. SESSION 1: DEFINING AND UNDERSTANDING DIFFERENT TYPES OF

5.1.1.1 Session outline: 30 min

• Definition and types of OH during pregnancy, childbirth

5.1.1.3. Learning Objectives

5.1.1.4. Content of Session 1

Obstetrics haemorrhage can be broadly divided into the following:

B) Causes and predisposing factors of obstetric haemorrhage

ii). Bleeding in late pregnancy

iv) Intrapartum Haemorrhage: Bleeding that occurs during labour

ii) Factors due to inefficient management of pregnancy, labour and delivery:

iii) Other factors:

5.1.2. SESSION 2: BLEEDING DURING EARLY PREGNANCY

5.1.2.2. Session outline: 90 min

5.1.2.3. Learning Objectives

5.1.2.4. Content of Session 2

B. Classification: be classified according to localisation or clinical presentation

i) Classification according to the localisation

• Abdominal: Often is secondary to tubal, ovarian or tubo-ovarian.

• Rare forms: Cervical and ectopic combined with intrauterine pregnancy.

ii) Extra uterine pregnancy can present clinically as;

• Unruptured ectopic pregnancy.

Bleeding: Adnexal mass:

Amenorrhoea: Uterine size:

Dizziness and Fainting: Cervical Excitation:

Flow Chart No. 1

. Take general and

Confirm through paracentesis

5.1.3. SESSION 3: ABORTION

5.1.3.2. Session outline: 60 min

5.1.3.3. Learning Objectives

Spontaneous Abortion: This is abortion occurring without deliberate external intervention.

Habitual Abortion This is defined as three consecutive spontaneous abortion.

Induced Abortion Deliberate termination of pregnancy before the stage of viability.

Second Trimester: • Congenital infections e.g. syphilis

Trauma • Physical trauma on the gravid uterus

Other disorders • Psychological and emotional disorder

Clinical classification and management of abortion

STAGE OF ABORTION CLINICAL PRESENTATION MANAGEMENT

. abdominal cramps may or may not be . treat as emergency

. pelvic pain of varying degrees . iv line for rehydration

. signs and symptoms of . coagulation screen: clotting

D) GUIDELINE FOR THE MANAGEMENT OF SEPTIC ABORTION

Through history and physical examination