National and Unified Obstetric and Newborn care Guidelines and Protocols Strengthening Reproductive Health Management and Service Delivery in West Bank and Gaza
National and Unified Obstetric and Newborn care Guidelines and Protocols
Guidelines 1. Normal delivery 2. Breastfeeding 3. Normal care to the newborn 4. High risk cases (1 : medical conditions) 5. High risk cases (2 : obstetrical conditions) 6. Obstetrical Emergencies 7. Newborn High Risk and Emergencies 8. Obstetrical procedures 9. Neonatal procedures 10. Quality assessment National and Unified Obstetric and Newborn care Guidelines and Protocols
Guidelines 1. Normal delivery 2. Breastfeeding 3. Normal care to the newborn 4. High risk cases (1 : medical conditions) 5. High risk cases (2 : obstetrical conditions) 6. Obstetrical Emergencies 7. Newborn High Risk and Emergencies 8. Obstetrical procedures 9. Neonatal procedures 10. Quality assessment National and Unified Obstetric and Newborn care Guidelines and Protocols
High Risk Cases 1 st SECTION : The Mother and Foetus Topic 4: High risk cases A. Medical conditions B. Obstetrical conditions National and Unified Obstetric and Newborn care Guidelines and Protocols
High Risk Cases : obstetrical conditions 1 st SECTION : Mother and foetus Topic 4: High risk cases B. Obstetrical conditions 1. 2. 3. 4. 5. 6. 7. Management of severe pre-eclampsie Antepartum Haemorrhage Management of Pre-labor Rupture of Membranes Management of preterm labour Management of Breech Presentation at term Management of twins labour at term Management of previous uterine scar National and Unified Obstetric and Newborn care Guidelines and Protocols
High Risk Cases : obstetrical conditions For all Cases of High risk pregnancies, the following steps must be achieved These actions represent the First Step and general rules They are usually achieved by midwives or paramedical staff National and Unified Obstetric and Newborn care Guidelines and Protocols
High Risk Cases : obstetrical conditions ·Receive & admit the woman. ·Obtain initial history including; gestational age, complains, onset of bleeding, amount, fetal movements, antenatal care, previous obstetrics history, medical & surgical history. ·Perform abdominal exam assessing for Fundal height, lie, presentation, gestation. ·Check & document fetal heart sounds. ·Check & document initial vital signs. (Temp, BP, Pulse, Respiration) ·Perform CTG for 20 minutes. ·Withdraw blood for CBC, Blood type & RH, save blood for X-match, PT & PTT, electrolytes, KFT, LFT, urine analysis. ·Observe closely ·Check vital signs especially Pulse & BP every 15 -30 minutes, temp every 4 h. • Notify Physician if diastolic BP 100 mmhg. National and Unified Obstetric and Newborn care Guidelines and Protocols
High Risk Cases : obstetrical conditions ·Keep on continues monitoring if possible. If not available, check & document fetal heart sounds every 15 min. ·Insert Canula to K. V. O. & for fluid therapy & medication. ·Maintain strict intake & output records hourly. ·Check all urine. ·Keep emergency trolley at bed side. ·Assess for signs / symptoms of worsening hourly: ·Administer medication as per Physician order following medication protocols. ·Encourage Lateral recumbent position. ·Provide support, coaching & encouragement during process of labour & deliver ·Assist the physician during delivery. National and Unified Obstetric and Newborn care Guidelines and Protocols
High Risk Cases : obstetrical conditions Severe Pre – Eclampsia 1 Topic 4, B High Risk cases. Subtopic 1 Management of Severe Pre – Eclampsia Standard Statement Severe pre-eclampsia and eclampsia are major causes of maternal and feral morbidity and mortality. The risks are reduced by intensive monitoring and aggressive management. National and Unified Obstetric and Newborn care Guidelines and Protocols
High Risk Cases : obstetrical conditions Definition Severe Pre – Eclampsia 1 Indicators of severe disease: 1) severe hypertension MAP – mean arterial pressure >125 mm. Hg or Diastolic BP – diastolic pressure > 110 mm. Hg or SBP – systolic BP> 170 mm. Hg measured by automated oscillometric devices (Dinamap) with the correct size of cuff on 2 occasions (check Dinamap readings intermittently and compare with standard methods. ) 2. Proteinuria (3+ or 4+ on dipstick or >3 g / 24 hours) 3. Oliguria (<500 mls / 24 hours) 4. Symptoms: headache, visual symptoms, epigastric pain. 5. Signs: - hyperreflexia especially with more than 2 beats of ankle clonus - rapidly developing generalized oedema - hepatomegaly with tenderness 6. Haematological and biochemical signs - platelet count <100 x 109/1 - urate>0. 45 mmol/1 National and Unified Obstetric and Newborn care Guidelines and Protocols
High Risk Cases : obstetrical conditions Severe Pre – Eclampsia 1 Pre Eclampsia is a very severe condition The complications can affect q. The kidney q. The Hemostatic system q. The Brain q. The Cardio-vascular system q. The Liver q. The Ocular system National and Unified Obstetric and Newborn care Guidelines and Protocols
High Risk Cases : obstetrical conditions Severe Pre – Eclampsia 1 PROCESS: in case of preeclampsia In labor ward , specific ations for paramedical staff · Observe closely (Toxemic Chart). · Notify Physician if diastolic BP 100 mmhg. · Check all urine for protein. · Assess for signs / symptoms of worsening hourly · Observe closely for signs / symptoms of abruptio placenta & uteroplacental insufficency · Place the patient in a single quite room, decrease environmental stimuli as much as possible with special midwife · Do not leave the patient alone. · Manage labour as per normal protocol. · Notify the paediatrician to be attend delivery. · If asymptomatic, anticipate normal delivery. · Continue close observation especially during the 2 nd stage · Give oxytocin 10 units i. v. after delivery of the anterior shoulder · Observe for signs / symptoms of pulmonary oedema, National and Unified Obstetric and Newborn care Guidelines and Protocols
High Risk Cases : obstetrical conditions Severe Pre – Eclampsia 1 Assess for signs / symptoms of worsening hourly: q q q Headache Blurred vision Epigastric pain (Right upper quadrant pain) Change in level of consciousness. Nausea & vomiting National and Unified Obstetric and Newborn care Guidelines and Protocols
High Risk Cases : obstetrical conditions Severe Pre – Eclampsia 1 Observe closely for signs / symptoms of abruptio placenta Abdominal Pain Vaginal bleeding Maternal tachycardia Foetal distress National and Unified Obstetric and Newborn care Guidelines and Protocols
High Risk Cases : obstetrical conditions Severe Pre – Eclampsia 1 Observe for signs / symptoms of pulmonary edema o Chest Tightness o Shortness of breath o Shallow, rapid respiration. o Wheezing o Tachycardia o Watch for signs of DIC & seizures. National and Unified Obstetric and Newborn care Guidelines and Protocols
High Risk Cases : obstetrical conditions Severe Pre – Eclampsia 1 PRINCIPLES OF MANAGEMENT: r Control of blood pressure r Prevent convulsions using Mg. So 4 as per guidelines. r Treat eclampsia (as per protocol. ) r Restore plasma volume and maintain urine output r Perform baseline investigations and monitor progress r Prevent complications r Plan management of the pregnancy r Consider use of Dexamethasone in preterm if not contraindicated even in severe cases. r Plan postpartum management National and Unified Obstetric and Newborn care Guidelines and Protocols
High Risk Cases : obstetrical conditions Severe Pre – Eclampsia 1 Control of blood pressure g Slowly reduce blood pressure to safe levels h(MAP<125 mm. Hg, Diastolic BP<105 mm. Hg), g Avoid hypotension. g Aim to keep MAP between 115 -125 mm. Hg (Diastolic BP between 90 - 105 mm. Hg) g confirm the BP reading with Mercury Sphygmomanometer. when “Dinamap” (automatic BP reading machine) is used to record patient’s blood pressure. National and Unified Obstetric and Newborn care Guidelines and Protocols
High Risk Cases : obstetrical conditions Severe Pre – Eclampsia 1 Prevent convulsions using Mg. So 4 Anticonvulsants are indicated : • if there is severe hypertension which cannot be controlled by antihypertensives • and also proteinuria 3+ or 4+ • and hyper-reflexia (indicated by the presence of ankle clonus 2 or more beats) National and Unified Obstetric and Newborn care Guidelines and Protocols
High Risk Cases : obstetrical conditions Severe Pre – Eclampsia 1 Treatment eclampsia : Principles If a patent presents with eclampsia, initial management should aim at • control of convulsions • maintaining the airway • and preventing trauma to the patient (see protocol. ) National and Unified Obstetric and Newborn care Guidelines and Protocols
High Risk Cases : obstetrical conditions Severe Pre – Eclampsia 1 Restore plasma volume and maintain urine output Expansion of the plasma volume prior to antihypertensive Expansion of the plasma therapy minimizes the risk of hypotension and may improve the hypertension per se. Hypovolaemia is an important feature of pre-eclampsia caused by the loss of plasma proteins into the interstitial space and the urine. This is a Consultant decision National and Unified Obstetric and Newborn care Guidelines and Protocols
High Risk Cases : obstetrical conditions Severe Pre – Eclampsia 1 Plan management of the pregnancy timing of delivery hospital equipped with SCBU (Special care baby unit) National and Unified Obstetric and Newborn care Guidelines and Protocols
High Risk Cases : obstetrical conditions Severe Pre – Eclampsia 1 MANAGEMENT GUIDELINES DURING DELIVERY Timing of delivery deliver most patients with pre-eclampsia once the situation is under control. Fetal Assessment assess fetal well-being by CTG and ultrasound scan. Mode of delivery IUGR and fetal hypoxia are common and so a caesarean section is the most appropriate form of delivery. Induction of labour should be in labour ward (with continuous monitoring). Epidural anaesthesia If an epidural is used together with antihypertensive agents, hypotension may ensue, so measure BP at least every 15 mins. And preload the patient with 500 mls N saline IV. National and Unified Obstetric and Newborn care Guidelines and Protocols
High Risk Cases : obstetrical conditions Severe Pre – Eclampsia 1 MANAGEMENT GUIDELINES DURING DELIVERY 2 nd Stage of Labor Ventouse/Forceps delivery can be used if obstetrically indicated Oxytocin and Methergin oxytocin 10 iu i. v. should be given, with delivery of the anterior shoulder. If necessary an i. v. infusion of Oxytocin can be given after delivery. Syntometrine and Methergin are CONTRINDICATED 3 rd Stage of labor A physiological third stage is contraindicated Corticoids Consider use of Dexamethasone in preterm if not contraindicated, even in severe cases National and Unified Obstetric and Newborn care Guidelines and Protocols
High Risk Cases : obstetrical conditions Severe Pre – Eclampsia 1 RECOGNISE & PREVENT THE FOLLOWING COMPLICATIONS o Acute renal failure: o Coagulopathy o Cerebral haemorrhage o Cardiovascular complications o Hepatic complications o Ocular complications National and Unified Obstetric and Newborn care Guidelines and Protocols
High Risk Cases : obstetrical conditions Severe Pre – Eclampsia 1 RECOGNISE & PREVENT THE FOLLOWING COMPLICATIONS o Acute renal failure: Oliguria is common and may be improved by the treatment of hypovolaemia National and Unified Obstetric and Newborn care Guidelines and Protocols
High Risk Cases : obstetrical conditions Severe Pre – Eclampsia 1 RECOGNISE & PREVENT THE FOLLOWING COMPLICATIONS o Coagulopathy h Mild coagulation abnormalities, particularly a low platelet count. h In severe cases disseminated intravascular coagulation (DIC) occurs with § reduced platelet count, § elevated prothrombin time, § elevated fibrin degradation products, § low fibrinogen levels § and reduced factor VIII activity. Treatment involves replacement of coagulation factors with fresh frozen plasma, cryoprecipitate and platelets the haematologist’s opinion should be sought early in the case of abnormal clotting studies. Early delivery of the fetus is desirable. National and Unified Obstetric and Newborn care Guidelines and Protocols
High Risk Cases : obstetrical conditions Severe Pre – Eclampsia 1 RECOGNISE & PREVENT THE FOLLOWING COMPLICATIONS o Cerebral haemorrhage (Rare complication. ) The risk can be reduced by : Ø prevention of eclampsia, Ø control of hypertension Ø and correction of coagulation abnormalities National and Unified Obstetric and Newborn care Guidelines and Protocols
High Risk Cases : obstetrical conditions Severe Pre – Eclampsia 1 RECOGNIZE & PREVENT THE FOLLOWING COMPLICATIONS o Cardiovascular complications may complicate pre-eclampsia Ø Hypertensive cardiac failure, Ø cardiomyopathy Ø and coronary artery insufficiency . Seek a Cardiologist opinion. National and Unified Obstetric and Newborn care Guidelines and Protocols
High Risk Cases : obstetrical conditions Severe Pre – Eclampsia 1 RECOGNIZE & PREVENT THE FOLLOWING COMPLICATIONS o Hepatic complications Pre-eclampsia may be complicated by hepatic enlargement, haemorrhage and even rupture. Liver failure may occur in severe cases and is treated by supportive therapy. This may present as part of the HELLP syndrome § haemolysis/hypertension, § elevated liver transaminases, § low platelet count National and Unified Obstetric and Newborn care Guidelines and Protocols
High Risk Cases : obstetrical conditions Severe Pre – Eclampsia 1 RECOGNIZE & PREVENT THE FOLLOWING COMPLICATIONS o Ocular complications Eclampsia may be preceded by visual disturbance, particularly seeing flashing lights or stars. Retinal haemorrhage or detachment and macular oedema may cause reduced acuity National and Unified Obstetric and Newborn care Guidelines and Protocols
High Risk Cases : obstetrical conditions Severe Pre – Eclampsia 1 MANAGEMENT of SEVERE PRE-ECLAMPSIA : ASSESSMENT o Transfer the patient to labour ward. o Initiate an emergency observation chart for each patient o Record the vital parameters o Investigate Lab tests: (1 -4 repeated every 12 hours) o Manage labour according to protocol : National and Unified Obstetric and Newborn care Guidelines and Protocols
High Risk Cases : obstetrical conditions Severe Pre – Eclampsia 1 1. Transfer the patient to labour ward If Ø diastolic BP>110 mm Hg, Ø systolic BP>170 mm Hg, Ø MAP>125 mm Hg on two occasions 5 -10 mins apart. National and Unified Obstetric and Newborn care Guidelines and Protocols
High Risk Cases : obstetrical conditions Severe Pre – Eclampsia 1 2. Initiate an emergency observation chart for each patient providing a complete record of the patient’s observations, fluid balance and investigation results as indicated below: v Gestational age and size v Amount of amniotic fluid v Uterine irritability or contractions v Fetal condition – clinical and CTG Check FHR every 15 minutes. v Other pregnancy complications v multiple pregnancy, v preterm labour, v abruption. v Weight of patient National and Unified Obstetric and Newborn care Guidelines and Protocols
High Risk Cases : obstetrical conditions Severe Pre – Eclampsia 1 3. Record the followings parameters: § § Ø Blood pressure using dinamap (every 15 mins or every 5 mins if Map>140 mm. Hg). Confirm with the mercury sphygmomanometer. Ø National and Unified Obstetric and Newborn care Guidelines and Protocols
High Risk Cases : obstetrical conditions Severe Pre – Eclampsia 1 4. Investigate the following Lab tests 1 -4 repeated every 12 h. o Full blood count – haemoglobin (N. B high = haemoconcentration) and platelets. o Coagulation screen (including FDPs if any other abnormality). o Renal function tests – creatinine, urea electrolytes, urate. o Liver function tests and serum protein levels. o Hourly urine collection for protein, if time prior to delivery allow, collect a 24 hour urine for protein and creatinine clearance. MSU for microscopy (evidence of renal disease – granular casts, rule out infection) National and Unified Obstetric and Newborn care Guidelines and Protocols
High Risk Cases : obstetrical conditions Severe Pre – Eclampsia 1 5. Manage labour as followed § Consider expediting. § All inductions of labour performed in labour ward (including prostin method). § Preload patients with an additional 500 mls N-saline (0. 9%) before epidural. § Consider ventouse/forceps delivery if indicated. § Oxytocin (syntocinone) 10 iu i. v. (NO syntometrine in third stage. ) National and Unified Obstetric and Newborn care Guidelines and Protocols
High Risk Cases : obstetrical conditions Severe Pre – Eclampsia 1 TREATMENT REGIMENS FOR SEVERE PRE-ECLAMPSIA (see separate leaflet for doses) Initial control of BP: Hydralazine – DO NOT mix with dextrose Labetalol – Not to be used with ASTHMA or CARDIAC PATHOLOGY. Nifedipine (Retard Tablets): (be careful if Mgso 4 is used as well. ) Maintain BP by: Hydralazine Labetalol Nifedipine (Retard Tablets); be aware that Nifedipine potentiates the action of magnesium sulphate Magnesium Sulfate : its efficacy is well established in treatment. National and Unified Obstetric and Newborn care Guidelines and Protocols
High Risk Cases : obstetrical conditions Severe Pre – Eclampsia 1 ABOUT MAGNESIUM SULFATE (see separate leaflet for regimen and doses) Indications for Magnesium Sulfate: Severe hypertension (MAP> 125 mm. Hg, Diastolic BP> 110 mm. Hg) after 1 hour of parenteral therapy and proteinuria 3+ or 4+ plus hyperreflexia with clonus (4 beats or more) or epigastric pain. Contraindications of Magnesium Sulfate: Renal failure or severe oliguria Cardiac disease Bolus dose ØMust be given through a separate cannula. Initially, administer 20 ml (4 g) of magnesium sulphate i. v. as 20% solution over 10 minutes. ØAlternate method: dilute 4 g Mg. SO 4 in 80 ml of N/S to end up with 100 ml solution and infuse it slowly 10 ml/minute v. To be administered by resident doctor. National and Unified Obstetric and Newborn care Guidelines and Protocols
High Risk Cases : obstetrical conditions Ante partum Hemorrhage 2 Topic 4, B High Risk Cases Stopped Here Subtopic 2 Management of Ante partum Hemorrhage Standard Statement Obstetric hemorrhage (APH, PPH, Bleeding in early pregnancy) is one of the 3 most common causes of maternal death in the developing countries. National and Unified Obstetric and Newborn care Guidelines and Protocols
High Risk Cases : obstetrical conditions Ante partum Hemorrhage 2 ETIOLOGY Bleeding from the genital tract after 24 weeks gestation may be due to : o Placenta previa o Placental abruption o Local conditions of cervix, vagina, vulva o Vasa previa o Consider other rare lesions e. g. hemorrhoids o Bleeding disorders. National and Unified Obstetric and Newborn care Guidelines and Protocols
High Risk Cases : obstetrical conditions Ante partum Hemorrhage 2 ACTIONS: If moderate or major bleeding Keep NPO till further decision form the consultant or Registrar/Senior resident. First step PLUS the followings, F Call for help. F Consider taking obstetric emergency trolley bedside. F Insert IV Canula G 14 & initiate Hartmann's solution/Ringer lactate. F Insert catheter. F Measure intake & output Q ½ hour. F Observe & measure bleeding closely & consider weighing linens & saving soaked pads for review. National and Unified Obstetric and Newborn care Guidelines and Protocols
High Risk Cases : obstetrical conditions Ante partum Hemorrhage 2 ACTIONS: If Minor ante partum hemorrhage • Obtain a detailed history (precipitating factors and amount of blood Loss), • Perform a general examination • Check gestation. • Check & evaluate the CTG. & ultrasound reports for placental site. • Perform gentle speculum examinations, unless known to have major placenta previa or if no ultrasound report available • Check lab results & give anti D if Rhesus negative. • Transfer to ward if no signs of major bleeding, significant uterine tenderness or fetal distress. If term consider induction of labor after discussing with Consultant. If preterm give dexamethazone (as detailed in PTL protocol) National and Unified Obstetric and Newborn care Guidelines and Protocols
High Risk Cases : obstetrical conditions Ante partum Hemorrhage 2 Obtain a detailed history (noting precipitating factors and amount of blood Loss), F Time of the onset of bleeding & the activities at the time prior to the bleeding. F History of previous episode of bleeding F Amount of bleeding F Any history of e pain, e trauma, e sexual intercourse e & uterine contractions. National and Unified Obstetric and Newborn care Guidelines and Protocols
High Risk Cases : obstetrical conditions Ante partum Hemorrhage 2 Perform a general examination especially F for signs of uterine tenderness. F Check the vital signs Immediately. F Estimate the blood loss F Immediate assessment of the abdomen i Fundal height i Consistency of the abdomen i Position of the fetus i Uterine contractions or irritability i Uterine tenderness i Presence of fetal heart National and Unified Obstetric and Newborn care Guidelines and Protocols
High Risk Cases : obstetrical conditions Ante partum Hemorrhage 2 ALGORITHM : Antepartum hemorrhage : first steps Ante partum hemorrhage Blood sample Group, Count Rh ? Neg Pos Associated severe signs q Major bleeding Anti D q Fetal distress q Uterine tenderness National and Unified Obstetric and Newborn care Guidelines and Protocols
High Risk Cases : obstetrical conditions Ante partum Hemorrhage 2 Present Associated severe tenderness Absent Speculum : Col - Vagina Abnormal Normal Term ? Refer < 37 sem >= 37 sem Cervix ? Non Favourable ALGORITHM : Antepartum hemorrhage : first steps Favourable Induction Corticoids + follow-up US CTG BLOOD Ex National and Unified Obstetric and Newborn care Guidelines and Protocols
High Risk Cases : obstetrical conditions Ante partum Hemorrhage 2 Specific rules 1. Catheterize for accurate monitoring of urinary output 2. Record observations on observation chart and measure all blood loss accurately (consider weighing soaked linen) keep all pads for review 3. Inform • Anesthetist • Neonatal unit 4. Discuss with consultant 5. If clotting studies are abnormal discuss with hematologisit 6. Give • ranitidine 50 mg in 20 mls saline slowly (over 2 mins) IV (unless already given orally) • and metoclopramide 10 mg (over 2 mins) IV. National and Unified Obstetric and Newborn care Guidelines and Protocols
High Risk Cases : obstetrical conditions Ante partum Hemorrhage 2 Specific rules • Delivery should be effected. If no evidence of placenta previa, the cervix is favorable and there is no fetal distress, induction of labor may be appropriate, labour often progresses rapidly in the event of APH due to placental abruption. • There should be early recourse to caesarean section if blood loss increases or if there are subtle signs of maternal shock e. g. increasing tachycardia or fetal distress. Fit young woman maintain their blood pressure despite extensive bleeding • In all other circumstances proceed immediately to caesarean section. • The patient should be closely monitored in the labor ward until her condition is satisfactory. Observations continued in ICU observation chart. DO NOT give diclofenac (Voltarol) : Risk of bleeding & renal shut down. National and Unified Obstetric and Newborn care Guidelines and Protocols
High Risk Cases : obstetrical conditions Ante partum Hemorrhage 2 If Major ante partum HH (blood loss in excess of 1000 mls) or abruption resulting in fetal death, add the following steps Always inform consultant Collect obstetric emergency trolley. Cross match at least 6 units of blood. Give Oxygen Blood transfusion as soon as possible Deliver by caesarean section immediately if the fetus is still alive. In the event of fetal death, mode of delivery is to be decided by Consultant. Decision for a vaginal delivery will be considered with an overall view of the patient’s clinical scenario. Clotting studies should be repeated every 4 hours for the first 12 hours. After delivery, maintain an Oxytocin infusion in Hartmann’s solution National and Unified Obstetric and Newborn care Guidelines and Protocols
High Risk Cases : obstetrical conditions Ante partum Hemorrhage 2 Blood transfusion as soon as possible 1. If life threatening bleeding, other relevant blood groups. (i. e. Rh O –ve blood) are given with out cross matching. 2. If the patient is showing signs of coagulation defects, further steps are taken to obtain blood products i. e. • • • Fresh Frozen Plasma Platelets Cryoprecipitate 3. CVP line is to be considered ( inserted by the anesthetist) 4. If there has been an abruption extensive enough to result in fetal death the patient will always require at least 4 units of blood whatever the initial hemoglobin level and this should be given as soon as the cross match is completed National and Unified Obstetric and Newborn care Guidelines and Protocols
High Risk Cases : obstetrical conditions Ante partum Hemorrhage 2 In the event of fetal death, the mode of delivery is to be decided by the Consultant. 1. Induction of labor with very careful observation of maternal condition may be appropriate if the maternal condition is stable and if labor progresses rapidly. 2. Even if the fetus is dead, immediate caesarean section may well be preferable UNLESS the cervix is found to be at least 4 cms dilated in which case it may be reasonable to perform an ARM and augment labour with oxytocin. 3. A caesarean section may still be necessary unless progress of labor is rapid. National and Unified Obstetric and Newborn care Guidelines and Protocols
High Risk Cases : obstetrical conditions Ante partum Hemorrhage 2 Clinica. L assessment ALGORITHM Ante partum or Per partum haemorrhage Intensive care if necessary + Ultrasound Placenta previa Abruptio placentae Type ? Type I or II Type III or IV See Algorithm Placenta previa I or II See Algorithm Placenta previa III or IV See Algorithm Abruptio Placentae National and Unified Obstetric and Newborn care Guidelines and Protocols
High Risk Cases : obstetrical conditions Ante partum Hemorrhage 2 Placenta previa I or II ALGORITHM Placenta previa Type I or II Blood Loss Amount ? Minimal blod loss Excessive blood loss Term ? Vital signs ? < 37 weeks > 37 weeks Observe Monitor untill 37 weeks Vaginal delivery + Manual delivery of placenta Normal Pre-shock ARM if in Labour + Oxytocics Failure Dystocia Hemorrhage Ceasarean National and Unified Obstetric and Newborn care Guidelines and Protocols
High Risk Cases : obstetrical conditions Ante partum Hemorrhage 2 ALGORITHM Placenta previa Type III or IV Placenta previa III or IV Blood Loss Amount ? Minimal blod loss Excessive blood loss Term ? < 37 weeks Observe Monitor untill 37 weeks in Hospital > 37 weeks Caesarean National and Unified Obstetric and Newborn care Guidelines and Protocols
High Risk Cases : obstetrical conditions Ante partum Hemorrhage 2 ALGORITH M Abruptio Placentae General Assessment Fœtal Status Dead Alive DIC ? YES Resuscitation Transfer in ICU Normal Fœtal Distress ? NO YES NO Cervical Maturity Induction Failure Caesarean Non favourable cervix Favourable cervix ARM Shock Dystocia Normal Vaginal delivery Manual delivery of placenta Ocytocics National and Unified Obstetric and Newborn care Guidelines and Protocols
High Risk Cases : obstetrical conditions pre-labor rupture membranes 3 Topic 4, B High Risk Cases Subtopic 3 Management of pre-labor rupture membranes Standard Statement Manage as an inpatient - gestational age is the single most important element. Definition PROM premature rupture of membranes is membrane rupture occurring before the ondet of labour, irrespective of gestation National and Unified Obstetric and Newborn care Guidelines and Protocols
High Risk Cases : obstetrical conditions pre-labor rupture membranes 3 Management : Specific Actions 1. Admit the woman and follow the routine admission procedures. 2. Conduct a detailed history with particular focus on dates. 3. Perform a complete physical exam and search for contractions. 4. Confirm membranes status by performing a sterile speculum exam, 5. Conduct the following investigations: 1. Complete blood count 2. Intracervical and HVS for culture and sensitivity 3. MSU for culture and sensitivity 4. Ultrasound assessment of fetal status if labour is not advanced. 5. CTG if pregnancy reached 28 weeks. 6. If labour is inevitable: Inform neonatal unit and check cot state. National and Unified Obstetric and Newborn care Guidelines and Protocols
High Risk Cases : obstetrical conditions pre-labor rupture membranes 3 Management of PROM according to Gestational age Gestation between 26 -33 weeks + 6 j If not associated with uterine contractions, conservative management If contractions, to suppress labour is an Consultant’s decision Conservative management TOCOLYSIS If uterine contractions, suppress labour after excluding contra indications. STEROIDS : Steroids enhance fetal lung maturity: 2 doses of 12 mg betamethazone/dexamethasone IM 12 h apart in the first 24 hours Repeat the course only once if PROM occurred before 29 weeks. ANTIBIOTICS: Give a single course of erythromycin 500 mg 6 hourly for 5 days. Alternatively Augmentin 375 mg 8 hourly for 7 days. National and Unified Obstetric and Newborn care Guidelines and Protocols
High Risk Cases : obstetrical conditions pre-labor rupture membranes 3 Contra indications to tocolyse 1. Fetal death 2. Fetal distress 3. Fetal abnormality incompatible with survival 4. Chorioamnionitis 5. Antepartum haemorrhage 6. Medical conitions: Cardiac disease and Hyperthyroidism 7. Obstetric indication for delivery e. g. severe pereclampsia etc. 8. Advanced labour i. e. cervical dilatation of 4 cm or more National and Unified Obstetric and Newborn care Guidelines and Protocols
High Risk Cases : obstetrical conditions pre-labor rupture membranes 3 Management of PROM according to Gestational age Gestation between 26 -33 weeks + 6 j : Conservative M. : Follow-UP • Daily palpation for tender uterus, assessment of liquor color & CTG. • Check white cell count + CRP twice/week. • Weekly Scan for estimated fetal weight and biophysical profile If there is any evidence of infection, hemorrhage or fetal distress then labor should be induced or rarely a caesarean section may be appropriate (Consultants must be aware of such cases). In the case of suspected sepsis antibiotics should be commenced immediately. If the results of an HVS suggest a specific organism appropriate antibiotics Otherwise commence cefuroxime 1. 5 g loading dose then 750 mg 8 hourly IV and metronidazole 1 g PR 12 hourly. Labor will be induced by an Oxytocin infusion and managed as for preterm labor. National and Unified Obstetric and Newborn care Guidelines and Protocols
High Risk Cases : obstetrical conditions pre-labor rupture membranes 3 Management of PROM according to Gestational age Gestation between 34 -37 weeks These patients should be discussed with the Consultant on call as be appropriate to treat them either as for preterm or as for term National and Unified Obstetric and Newborn care Guidelines and Protocols
High Risk Cases : obstetrical conditions pre-labor rupture membranes 3 Management of PROM according to Gestational age Gestation >37 weeks 1. expectant management is preferable as labor will ensure spontaneously within 24 hours in 70 -90 % of these women. 2. Digital vaginal examination is not indicated. 3. IF pyrexia, offensive vaginal discharge, B hemolytic streptococcus carrier Oxytocin immediately to induce labor: Intravenous penicillin 3 g, then 1. 5 g four-hourly until delivery. Clindamycin 900 mg intravenously eight-hourly if allergy Avoid Broad-spectrum antibiotics such as ampicillin, 4. If meconium, fetal tachycardia or decelerations, consider delivery by LSCS. National and Unified Obstetric and Newborn care Guidelines and Protocols
High Risk Cases : obstetrical conditions pre-labor rupture membranes 3 EXPECTANT MANAGEMENT SHOULD BE : 1. Admit to antenatal bed 2. Observe 4 hourly pulse, temperature 3. Fetal heart rate CTG twice daily. 4. Vaginal examination if painful contractions start. 5. No prophylactic antibiotics. 6. Labor should be induced at 6 am approximately 24 hours after rupture of the membranes. National and Unified Obstetric and Newborn care Guidelines and Protocols
High Risk Cases : obstetrical conditions pre-labor rupture membranes 3 INDUCTION OF LABOR preferably induced by PGE 2 (Prostin) Nulliparous with Bishop score of < 4, should receive 3 mg prostin, Nulliparous with Bishop score of > 4 and All Multiparous should receive 1. 5 mg prostin. Prostin dose can be repeated Q/6 hours up to 3 doses, 4 th dose can be given after evaluation by Consultant. If the cervix is favorable, patient is transferred to labour ward and labor is induced with oxytocin. (oxytocin should be commenced after the elapse of 6 houres after the last prostin dose). If cervix remained unfavourable, patient may rest for 24 hour and another course of IOL with prostin pessaries is re-used thereafter. If after six doses of prostaglandin the cervix remains unfavorable for ARM, the mode of delivery has to be reviewed by the consultant concerned. National and Unified Obstetric and Newborn care Guidelines and Protocols
High Risk Cases : obstetrical conditions pre-labor rupture membranes 3 ALGORITHM : PROM 1 Yes Induction + Antibiotics PROM Clinical Signs ? Pyrexia Offensive Vaginal discharge B streptococus Carrier + WBC , CRP, CTG, US NO Term ? < 34 wks Normal VD 34 -36 wks >36 wks Failure Fetal destress See Algorithm PROM 2 Caesarean National and Unified Obstetric and Newborn care Guidelines and Protocols
High Risk Cases : obstetrical conditions pre-labor rupture membranes 3 ALGORITHM : PROM 2 PROM No Clinical Signs – No Biological Signs Term ? < 34 wks Antibiotics Cortocoids Tocolysis Caesarean >36 wks Wait Contractions ? Yes 34 -36 wks No Follow-up Wait 24 hrs Labour Normal VD Failure Fetal destress No labour Induction Normal VD National and Unified Obstetric and Newborn care Guidelines and Protocols
High Risk Cases : obstetrical conditions preterm labor 4 Topic 4, B High Risk Cases Subtopic 4 Management of preterm labor Standard Statement As PTL remains one of the most important causes of bad obstetric outcome, always admit patients and involve consultant. National and Unified Obstetric and Newborn care Guidelines and Protocols
High Risk Cases : obstetrical conditions preterm labor 4 Ethical considerations Ø Do not suppress labor after 34 weeks in view of the excellent neonatal facilities in Tertiary Hospitals. Ø Spontaneous miscarriages between 20 and 24 weeks gestation are usually managed in the labor ward and should be treated them as for preterm labor. However, during labor, fetal monitoring is not usually appropriate and vaginal delivery should be planned regardless of presentation. Ø A pediatrician should be informed of the impending delivery, after 22 weeks gestation although it should be clearly explained to the parents that this is to assess the baby and not necessarily to provide active resuscitation for the baby. National and Unified Obstetric and Newborn care Guidelines and Protocols
High Risk Cases : obstetrical conditions preterm labor 4 Management : Specific Actions All women with suspected preterm labor is seen by the physician Check gestation by dates and scan results. Examine to determine size and presentation Evaluate the CTG. Inform neonatal unit The following investigations are required • Full blood count • MSU-consider urgent microscopy if there is proteinuria • Speculum and intracevical swab (ICS & HVS) If membranes intact and contractions, a vaginal examination Search the etiology If membranes are ruptured refer to PROM protocol. If contractions are 3/10’ or more commence TOCOLYSIS ritodrine and give steroids National and Unified Obstetric and Newborn care Guidelines and Protocols
High Risk Cases : obstetrical conditions preterm labor 4 TOCOLYSIS : SUPPRESSION OF PRETERM LABOR 1. It is rarely indicated after 34 weeks gestation and is unlikely to be successful once cervical dilatation is 4 cms or more. 2. Only indicated in order to delay delivery by 48 hours to allow Dexamethazon in fetal maturation or to allow in utero transfer 3. If a tocolytic drug is used, ritodrine no longer seems the best choice. Atosiban or nifedipine appear preferable as they have fewer adverse effects and seem to have comparable effectiveness. Nifedipine Regimen should be the first choice now National and Unified Obstetric and Newborn care Guidelines and Protocols
High Risk Cases : obstetrical conditions preterm labor 4 TOCOLYSIS : Regimen for intravenous ritodrine infusion An infusion using a syringe pump ritodrine (Yutopar) in % dextrose. The infusion is commenced at 1 ml/hr and increased every 10 mins from 1 -2 -3 -4 -5 -6 to maximum (400 µg /min) or until contractions cease or maternal pulse > 140 bpm or systolic BP>160 mm. Hg. Strict fluid balance records are needed urine should be tested for glucose and ketones. Pulmonary edema is recognized Once contractions have ceased the infusion is left at that rate for 1 hour The infusion is then reduced by 1 ml/hr every 30 mins until the lowest rate required keeping the patient contraction free is reached. The infusion should be discontinued once the patient has been contraction free for 6 -8 hours. National and Unified Obstetric and Newborn care Guidelines and Protocols
High Risk Cases : obstetrical conditions preterm labor 4 TOCOLYSIS : Monitoring whilst on ritodrine: 1. Watch for alert symptoms Discontinue infusion if any symptom 2. Check maternal pulse Discontinue the infusion if > 120 pm. 3. Check the Blood Pressure Discontinue infusion if the BP drops. 4. Estimate blood glucose levels caution if diabetic patients 5. Strict record of fluid balance input/output chart 6. Auscultate lung fields Discontinue infusion if pulmonary oedema and give lasix. 7. Check blood urea and electrolytes. 8. Practice ECG 24 hourly ( potassium deficiency) 9. U + Es 10. CTG : contractions and FHR. National and Unified Obstetric and Newborn care Guidelines and Protocols
High Risk Cases : obstetrical conditions preterm labor 4 TOCOLYSIS : Monitoring whilst on ritodrine: Discontinue infusion if any of the followings alert symptoms q Palpitations q Tremors q Nausea q Vomiting q Headache q Restlessness National and Unified Obstetric and Newborn care Guidelines and Protocols
High Risk Cases : obstetrical conditions preterm labor 4 TOCOLYSIS : Contraindications to ritodrine: 1. Absolute contraindications: v Ante partum hemorrhage v Chorioamnionitis v Eclampsia/fulminating pre-eclampsia v Intrauterine fetal death v Maternal cardiac disease 2. Relative contraindications: v Diabetes mellitus v Rupture of membranes. Ritodrine is indicated in order to delay labor for 48 hours after the administration of steroid unless there any signs of infection National and Unified Obstetric and Newborn care Guidelines and Protocols
High Risk Cases : obstetrical conditions preterm labor 4 TOCOLYSIS : Side effects of Ritodrine: Ø Pulmonary edema (indicated by dry cough /chest pain /dyspnea) Ø Tachycardia, palpitations Ø Anxiety, sweating Ø Tremor Ø Hypokalaemia National and Unified Obstetric and Newborn care Guidelines and Protocols
High Risk Cases : obstetrical conditions preterm labor 4 TOCOLYSIS : Regime for Nifedipine Tocolysis: Ø 10 mgs orally (NOT SUBLINGUAL) repeated every 20 minutes up to a maximum of 40 mgs. Ø Maintenance 10 -20 mgs tid for 48 hrs. Ø Patient must be monitored for BP and pulse Ø CTG monitoring is essential. National and Unified Obstetric and Newborn care Guidelines and Protocols
High Risk Cases : obstetrical conditions ALGORITHM : PRETERM LABOUR 1 preterm labor 4 Contractions Vag Exam Cerv. Dilat. >4 cm Cerv. Dilat. <4 cm CTG Term ? Risk Assesment >= 34 wks Weak Mild < 34 wks High Refer Or Transfer See Algorithm Preterm 2 National and Unified Obstetric and Newborn care Guidelines and Protocols
High Risk Cases : obstetrical conditions preterm labor 4 Weak High Rest Progestin OK Mild Rest Progestin Failure Orally tocolytic IV Tocolytic corticoids OK Failure OK >= 34 wks ALGORITHM : PRETERM LABOUR 1 Failure Term ? Stop Treat < 34 wks Refer Or Transfer National and Unified Obstetric and Newborn care Guidelines and Protocols
High Risk Cases : obstetrical conditions preterm labor 4 STEROID THERAPY : PROMOTING PULMONARY MATURITY 1. All women with potential or actual threatened preterm labor between 24 and 35 weeks should be given steroids even if delivery is imminent. 2. 2 doses of 12 mg Betamethasone/dexamethasone IM given 12 hours apart 3. Aim to delay labor for a further 24 hours for maximum benefit 4. Rupture of the membranes is not a contra-indication to steroid therapy 5. Diabetic patient -see diabetes protocol 6. Repeated doses of Betamethasone/dexamethosone if the first doses were given before 29 completed weeks after discussion with the consultant in charge. National and Unified Obstetric and Newborn care Guidelines and Protocols
High Risk Cases : obstetrical conditions preterm labor 4 DELIVERY: v Breech presentations discussed with the Consultant v Cephalic presentation should be allowed to deliver vaginally v CTG (and Fetal Scalp Sampling) v Episiotomy v Elective forceps delivery is not necessary. v Pediatricians present at all preterm deliveries. v A swab should be taken from the placenta v and the placenta sent to histology National and Unified Obstetric and Newborn care Guidelines and Protocols
High Risk Cases : obstetrical conditions Breech presentation 5 Topic 4, B High Risk Cases Subtopic 5 Management Breech presentation at term Standard Statement Even if a clear management plan is written in the notes, consultant Must be informed upon admission as the management needs to be individualized National and Unified Obstetric and Newborn care Guidelines and Protocols
High Risk Cases : obstetrical conditions Breech presentation 5 Management : 1. Obtain initial history 2. Perform abdominal exam 3. Perform the routine admission procedures. 4. Check CBC, Blood type & Rh, save blood for X-match. • external cephalic version (ECV) in absence of contraindications 1. term frank or complete breech singleton : caesarean section. 2. Primigravidae with breech presentation by CS. 3. Deliver all footling breech by CS. National and Unified Obstetric and Newborn care Guidelines and Protocols
High Risk Cases : obstetrical conditions Breech presentation 5 Specific Actions in case of breech presentation 1. Do not induce/and or use Oxytocin to accelerate labor. Induction or augmentation may be justified in selected cases. (Consultant decision). 2. Breech extraction ONLY in the case of a second Twin or dead fetus 3. Only senior doctor with proven experience should conduct the delivery. 4. Forceps should be available in advance. 5. When the fetal heart rate trace is suspicious, fetal blood sampling 6. An Anesthetist as well as pediatrician should attend the delivery. 7. Explain the delivery procedure to the patient and her husband. 8. Allow pregnancy to continue up to 40 weeks +10 days 9. PROM and pre-term labour are managed as in relevant protocol. National and Unified Obstetric and Newborn care Guidelines and Protocols
High Risk Cases : obstetrical conditions Breech presentation 5 All women with an uncomplicated breech pregnancy at term (37 -42 weeks) should be offered external cephalic version (ECV) in the absence of contraindications. 1. ECV should be undertaken by consultant or a well trained registrar under direct consultant supervision. 2. Tocolysis is helpful, and should be used as a routine in primigravidas. 3. Perform ECV while the mother awake and facilities for emergency CS delivery are available nearby. 4. Confirm fetal; well being with cardiotocography before and after ECV, Ultrasound guidance can be helpful. 5. Do not use regional anaesthesia to facilitate ECV, evidences is insufficient to support its use. National and Unified Obstetric and Newborn care Guidelines and Protocols
High Risk Cases : obstetrical conditions Breech presentation 5 PARTICULAR CONDITIONS : 1. If Multigravidae: May be considered for vaginal breech delivery if: v No other obstetrics/medical problem v Clinically adequate pelvis. v Scan estimation of F. W, Not more than 3500 gm at 38 weeks , v of frank or complete breech. Explain to the mother and give her time to discuss the choice with her husband/relatives. National and Unified Obstetric and Newborn care Guidelines and Protocols
High Risk Cases : obstetrical conditions Breech presentation 5 PARTICULAR CONDITIONS : 2. If trial of labor (in breech) Trial of labour in breech presentation : consultant’s decision 1. Vaginal breech delivery should be carried out by the most senior Doctor available 2. Immediate vaginal Examination if SROM. 3. Ask for Blood grouping and X – Matching. 4. Epidural analgesia can be employed. 5. Full dilatation of the cervix confirmed by experienced midwife or obstetrician 6. Keep on continuous electronic fetal heart monitoring. Stop trial of labour and consider C/S if : Ø Rate of cervical dilatation is < 1 cm/hr Ø If the breech fails to descend. Ø If there is evidence of fetal distress. National and Unified Obstetric and Newborn care Guidelines and Protocols
High Risk Cases : obstetrical conditions Breech presentation 5 PARTICULAR CONDITIONS : Preterm breech delivery Ø Up to 28 weeks allow for vaginal delivery. Ø 28 – 34 weeks : Individual Consultant decision. Ø 35 -37 weeks : Manage as term breech regarding. Do not perform ECV before term (37 weeks) There is insufficient evidence to support routine caesarean section for the delivery of preterm breech National and Unified Obstetric and Newborn care Guidelines and Protocols
High Risk Cases : obstetrical conditions Twins at Term 6 Topic 4, B High Risk Cases Subtopic 6 Management of Twins at Term in labor Standard Statement Twin pregnancy is associated with higher perinatal mortality especially in the second twin, and increased maternall morbidity. - National and Unified Obstetric and Newborn care Guidelines and Protocols
High Risk Cases : obstetrical conditions Twins at Term 6 Specific Actions Inform the Consultant of the admission If the first twin is Breech , perform C/S epidural analgesia if the woman desired so. Obstetric Registrar, anesthetist, pediatricians to be present Oxytocin infusion prepared for use in second stage Once the first twin is delivered, v Clamp the cord and divide. Do NOT give syntometrine. v Check presentation of the 2 nd twin abdominally, vaginally (and US Scan) v If contractions have not recommenced after 5 mins start an infusion of 10 IU Oxytocin v. Once the presenting part has descended into the pelvis, perform an ARM Aim for delivery of the second twin within 20 mins of the first if possible. The third stage managed actively. After delivery : infusion of 10 u Oxytocin in 500 mls Hartmann’s National and Unified Obstetric and Newborn care Guidelines and Protocols
High Risk Cases : obstetrical conditions Twins at Term 6 Specific Actions If the presenting part fails to descend, consider q a controlled ARM for a cephalic Presentation; q breech extraction for q a breech presentation q or persistent transverse lie. Breech extraction should be performed by grasping a foot PRIOR to rupturing the membranes and apart from extreme fetal distress should only be performed by an experienced registrar or Consultant. National and Unified Obstetric and Newborn care Guidelines and Protocols
High Risk Cases : obstetrical conditions Trial of labor 7 Topic 4, B High Risk Cases Subtopic 7 TRIAL of scar management (Trial of labor) Definition This will include patients with a previous caesarean section, hysterotomy, myomectomy, uterine perforation. National and Unified Obstetric and Newborn care Guidelines and Protocols
High Risk Cases : obstetrical conditions Trial of labor 7 MANAGEMENT Check that a decision for vaginal delivery has been made at a senior level (If no decision has been made, discuss with the Consultant ) Give ranitidine 150 mg orally 6 hourly during labor Inform Anaesthetist Perform 2 hourly vaginal examinations to check progress Watch for signs of scar dehiscence Assess the case carefully before using Oxytocin (on consultant’s order) Epidural analgesia could be used, however, do not epidural opiates as these may mask the pain of dehiscence /rupture. Progress in labor has to be almost ideal without much delay. Aim to achieve simple vaginal delivery at full dilatation. Be aware of post partum bleeding Do not palpate or inspect the previous scar after delivery, as a routine National and Unified Obstetric and Newborn care Guidelines and Protocols
High Risk Cases : obstetrical conditions Trial of labor 7 Watch for signs of scar dehiscence o o o Maternal tachycardia Vaginal bleeding Abnormal CTG inco-ordinate or cessation of uterine activity Severe lower abdominal pain present between contractions Presenting part getting higher National and Unified Obstetric and Newborn care Guidelines and Protocols
High Risk Cases : obstetrical conditions End of module 5 High Risk Cases obstetrical conditions National and Unified Obstetric and Newborn care Guidelines and Protocols
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