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2012 Edition of SGH Labour Ward Manual.

2012 Edition of SGH Labour Ward Manual.

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SGH Labour Ward Manual 2012 Document Transcript

  • 1. 1Department of O&G, Sarawak General Hospital
  • 2. PREFACEThe previous labour ward manual was updated in early 2010. Over the last 2 years, therehave been a number of changes and development in obstetric practice. It is due to thisreason an updated version of this manual becomes necessary. It has also come to ourknowledge that the previous manual was printed and used in other hospitals in Sarawak.It should be noted that the appropriate obstetric practice and plan of management forvarious clinical situations may differ slightly depending on the location, facilities,availability of clinical specialties and other support services. For the current manual somereference towards appropriate management in district hospitals are included.We hope that this manual would serve as a useful guide to doctors managing obstetricpatients in the labour ward.Dr. Harris N Suharjono FRCOGConsultant & HeadDepartment of Obstetrics & GynaecologySarawak General Hospital 2Department of O&G, Sarawak General Hospital
  • 3. CONTENTS1.0 EDITORIAL COMMITTEE 62.1 PATIENT ADMISSION CENTRE / LW TRIAGE 72.2 STANDARD OPERATING PROCEDURE & BASIC CARE 2.2.1 Documentation 14 2.2.2 Guidelines on general safety precautions 17 2.2.3 MOH Color coding for level of obstetric risk 20 2.2.4 Caesarean section – consent 23 2.2.5 Caesarean section - prophylaxis for acid aspiration 24 2.2.6 Ultrasound scan during labour 25 2.2.7 Thromboprophylaxis in pregnancy & puerperium 26 2.2.7.1 Thromboprophylaxis guidelines in vaginal 26 deliveries 2.2.7.2 Thromboprophylaxis guidelines in caesarean 28 sections. 2.2.7.3 Thromboprophylaxis guidelines during 29 pregnancy and puerperium 2.2.7.4 Guidelines for epidural anaesthesia in women 31 on thromboprophylaxis2.3 PROBLEMS IN PREGNANCY2.3.1 PIH/PE 331.3.2 Antihypertensive therapy 34 1.3.2.1 Hydralazine Infusion Regime 34 2.3.2.2 Labetalol Infusion Regime 351.3.3 Eclampsia 37 1.3.3.1 Magnesium Sulphate Regime 37 1.3.3.2 Diazepam Regime 392.3.4 HELLP Syndrome 402.3.5 Cardiac Disease in Pregnancy 412.3.6 Bronchial Asthma in labour 492.3.7 Diabetic mother in labour 512.3.8 Rhesus negative mother 542.3.9 HIV in pregnancy 562.3.10 Breech/ECV 612.3.11 Twins in labour 642.3.12 Trial of scar 662.3.13 Intrauterine death 68 3Department of O&G, Sarawak General Hospital
  • 4. 2.4 MANAGEMENT OF LABOUR2.4.1 Induction of labour 712.4.2 Augmentation of labour 752.4.3 Management of the first stage of labour 772.4.4 Management of the second stage of labour 792.4.5 Fetal monitoring in labour 802.4.6 Pain relief in labour 852.5 PROBLEMS ASSOCIATED WITH DELIVERY2.5.1 Episiotomy 882.5.2 Repair of cervical tears 902.5.3 Repair of vaginal and perineal tears 912.5.4 Instrumental delivery 942.5.5 Management of retained placenta 962.5.6 Preterm prelabour rupture of membranes (PPROM) 982.5.7 Prelabour rupture of membranes (PROM) 1002.5.8 Perinatal Group B Streptococcus Infection Prevention 1012.5.9 Preterm labour 103 2.5.9.1 Tocolytic for preterm labour 104 2.5.9.2 Tocolytic regime: Nifedipine 105 2.5.9.3 Tocolytic regime: Salbutamol 1062.5.10 Antepartum haemorrhage 108 2.5.10.1 APH: Abruptio placenta 108 2.5.10.2 APH: Placenta praevia 1102.5.11 Postpartum haemorrhage 1112.5.12 Guidelines for transfusion in massive blood loss 1192.5.13 Disseminated intravascular coagulation (DIVC) 120 2.5.13.1 Use of factor 7 (Novo 7) 1212.5.14 Uterine inversion 1242.5.15 Cord prolapsed 1292.5.l6 Shoulder dystocia 130 4Department of O&G, Sarawak General Hospital
  • 5. 3.0 APPENDICES3.1 Hydralazine infusion regime 1323.2 Labetolol infusion regime 1333.3 Magnesium Sulphate therapy 1343.4 Diazepam infusion regime 1353.5 Oxytocin augmentation / induction regime 1363.6 Nifedipine regime for tocolysis 1373.7 Salbutamol regime 1383.8 Heparin infusion regime 1393.9 Red Alert 1413.10 Indications for Pediatric referral 1423.11 Indications for Caesarean Section 1433.12 Guidelines for dating USS 1453.13 Sarawak PPH Box 1473.14 PPH management checklist 1483.15 Pictogram for estimation of blood loss 1493.16 Algorithm for the use of recombinant Factor 7 for PPH 1513.17 Guidelines on the management of low lying placenta in 152 district hospitals of Sarawak3.18 Interpretation of CTG 1553.19 Obstetric guidelines for district hospitals without O&G 159 specialist in Sarawak4.0 CONTACT NUMBERS4.1 Contact numbers of Consultants / Specialists / Medical Officers 1664.2 Important extension numbers 167 5Department of O&G, Sarawak General Hospital
  • 6. 1.0 EDITORIAL COMMITTEECHIEF EDITOR  Dr. Harris Njoo Suharjono FRCOGMEMBERS  Dr. Rafaie Amin M MED O&G  Dr. Nicholas Ngeh MRCOG  Dr. Edawati Dahrawi Edrus M MED O&G  Dr. Sim Wee Wee MRCOG  Dr. Sukanda Jaili M MED O&G  Dr. Lim Soon Hock MRCOG  Dr. Muniswaran Ganeshan MRCOG, M MED O&G 6Department of O&G, Sarawak General Hospital
  • 7. 2.1 PATIENT ADMISSION AREA / LW TRIAGE___________________________________________________________The Sarawak General Hospital‟s labour ward is the designated „Patient Admission Centre‟. Allantenatal patients are reviewed and admitted through the triage area of labour ward.Pregnant patients are admitted to receive inpatient care based on their identified healthcare needs and the organization‟s mission and resourcesIntent: 1) The department should accept cases referred from the primary/secondary sources or „walk in‟ cases for further pregnancy management of gestation more than 24 weeks. Those earlier than 24 weeks can be reviewed in the PAC but if requiring admission would be admitted to the gynaecology ward. 2) All obstetric wards are integrated wards (combined antenatal and postnatal care). 3) „Walk in‟ and referred patients need to be clerked, assessed and documented in patient‟s record at triage area by the nurses at the nursing counter. The patients will then have a CTG done and reviewed by a house officer. Any patients clerked by a house officer should be informed to a medical officer and the management agreed upon. 4) Admission shall be decided by the medical officer or the specialist on duty after his/her assessment. 5) Patients in labour shall be admitted directly to labour suite / labour room and other patients will be provided a bed in the obstetric ward as soon as a bed is available. 6) Patients waiting to be seen or are waiting for a bed to be available should be given breakfast/lunch or dinner at the time food is being served for other inpatients. 7) Postnatal mothers referred from outside agencies or birth before arrival (BBA) within 24 hours shall be admitted directly to the obstetric ward together with their babies. Newborn babies with complications shall be admitted to the Paediatric Unit. 8) All patients for admission need to have an admission form (Borang Arahan Kemasukan Wad – JRP 3/94(Pin. 1/06) and must be registered at the Admission Registration Counter. 7Department of O&G, Sarawak General Hospital
  • 8. 9) All patients for admission need to fill up an acknowledgment form regarding their valuables/ belongings (Borang Akuan Harta Benda Pesakit) at the Patient Admission Counter (PAC), including patients admitted from the antenatal clinic. 10) All inpatients shall be given a wrist identification tag and the babies would also be tagged accordingly. 11) Antenatal patients who are allowed to go home after being reviewed at the triage area by the house officer and the medical officer on duty. Should be counselled and given appropriate explanation. Such patients should be registered in a book placed in the nurse‟s counter. Input should include patient‟s data and a brief clinical finding. It should also state the name of the medical officer who has reviewed the patient. The patient‟s contact number should also be recorded and the husband or the person accompanying the patient should sign on the book. The patient should not be allowed to return home alone. 12) Patient who requested to be admitted even though the clinical finding does not necessitate an admission should be admitted for observation if a bed is available. 13) Patients who have difficulty to come back to the hospital, or who stays far from the hospital should be admitted. Patients with emergency or immediate medical needs should be given priority for assessment and treatment within 5 minutes of presentation.Intent: 1) Patients with emergency or immediate needs such as severe preeclampsia, bleeding placenta praevia are assessed and receive care as quickly as necessary. 2) Patients who need further attention or with immediate need, should be informed immediately to the medical officer / specialist in charge of the PAC or the Specialist On Call. 3) Appropriate referrals to other department shall be made accordingly.Measurable elements: 1) Staff shall recognize and prioritize patients with immediate needs 2) Medical officer / specialist shall be informed immediately. 3) Patients are prioritized based on the urgency of their needs.Emergency patients to be seen within 5 minutes by medical officer (Std:>95%)All patients cared for by the organization have their health care needs identifiedthrough established assessment process. 8Department of O&G, Sarawak General Hospital
  • 9. Access of care and Continuation of Care: StandardEach patient assessment(s) include an evaluation of physical, psychological, social andeconomic factors, including a physical examination and health history.Intent: 1) The assessment(s) of patient provide the information to : a) understand the care the patient is seeking b) select the best care setting for the patient c) form the initial diagnosis d) understand the patient‟s response to any previous care 2) Relevant investigations to form the diagnosis shall be sent a) Refer circulars on handling/ordering of lab investigations (Pengendalian Spesimen Makmal) b) Ordering radiologicalinvestigations (Permohonan Pemeriksaan Radiologi)Measurable elements:All patients shall have an initial assessment in Patient Admission Centre / in the wards forthe elective admission by the house officer / medical officer  1) The initial assessment(s) results in understanding any previous care and the care the patient is currently seeking.  2) The initial assessment(s) result in selecting the best setting for the care  3) The initial assessment(s) results in an initial diagnosis. Inappropriate admissions rate (Std: < 1%) At admission as an inpatient, patient and her family shall receive information on the proposed care, the expected outcome of that care, and in some circumstances the expected cost to the patient for that careIntent:Patient and family shall receive sufficient information to make knowledgeable decision.Information is provided about above matters. When financial constraints related to the costof care are present, the relevant authorities shall seek ways to overcome those constraints. 9Department of O&G, Sarawak General Hospital
  • 10. Measurable elements:  1) The staff and doctors shall provide the patient / family with information at admission on proposed care and the expected outcome.  2) Proper documentation shall be written in the patient‟s record regarding the information provided.  3) Patient shall receive sufficient information to make knowledgeable decisions.LABOUR ROOM/SUITELabour room / suite is a specialize area, taking care of mothers in labour. To ensureoptimum patient care and safety to mothers and their babies, appropriate guidelines shallbe followed for all procedures and activities. 1) During intrapartum period / postnatal period Refer to Protocol a) Management of normal delivery: „Pengendalian Kelahiran‟. b) Management of CTG: „Pengendalian CTG‟ c) Management of the placenta: „Pengendalian Uri‟ d) Vaginal examination: „ Proses pemeriksaan faraj‟ 2) Ensure babies‟ safety Refer „Pekeliling Ketua Pengarah Kesihatan Bil 1/2007 : Garispanduan Sistem Kawalan Keselamatan Bayi di Hospital-Hospital Kementerian Kesihatan Malaysia‟(Guidelines on Safety of Babies in Ministry of Health Hospitals) 3) Nurses and doctors are to follow strictly available SOP for the various steps in the management of patients and other clinical work processes.Discharges from labour ward 1) Staffs from labour room are responsible for transfer of postnatal mothers and their babies to the maternity wards 2) On receiving the mother and baby, the ward staff shall check their tags to verify their identification – „Correct baby to the correct mother‟. Ward staff shall go through the checklist – „Penilaian Postnatal‟ 3) Ensure babies‟ safety Refer „Pekeliling Ketua Pengarah Kesihatan Bil 1/2007 : Garispanduan Sistem Kawalan Keselamatan Bayi di Hospital-Hospital Kementerian Kesihatan Malaysia‟ (Guidelines on Safety of Babies in Ministry of Health Hospitals) 10Department of O&G, Sarawak General Hospital
  • 11. Transfer of babies from Labour ward 1) Labour suite staffs are responsible to transfer the babies that need to be admitted to Maternity Neonatal Intensive Care Unit (MNICU) after the Paediatric medical officer had discussed with the specialist and the approval obtained and documented. 2) Transfer of patient to other departments need to follow the hospital policy. a. Refer Guidelines on referrals to other departments: Pindah Keluar ke Wad Lain Dalam Hospital. 3) Transport arrangement shall be made for transfer to other department / hospital a. Refer Format for request for transport : Permohonan Perkhidmatan KenderaanMATERNITY OPERATION THEATRE________________________________________________________________________StandardsPatients are planned for elective and emergency caesarean section at maternity operationtheatre or the main OT.Standard: 1) Elective cases are planned earlier and performed from pre-determined hours (Monday to Friday, 8am-5pm). 2) All cases listed for operation are by a specialist 3) The patients are counseled regarding the indication, procedure and associated complications prior to the surgery and they area admitted one day prior to the day of operation. 4) The patients together with the husband are reviewed again by the obstetrician and gynaecologist who is planned to perform the operation 5) Necessary investigations are taken and reviewed prior to the operation. 6) All patients are reviewed by the anesthetist one day prior to the operation and are counseled again regarding the operation and type of anesthesia planned. 7) All high risk cases are performed by specialist/consultant. 8) Once the patient has been counseled, a written consent is taken from the patient. 11Department of O&G, Sarawak General Hospital
  • 12. 9) Blood is group and cross matched for all high risk cases according to the hospital protocols. Other patients shall have blood grouped and saved as appropriate. 10) A day prior to surgery a list is drawn up of all the cases and the Maternity Operation theater list is signed by the Head of Department. 11) The staff from the respective wards/units shall notify the staff of the Maternity Operation Theatre by means of an OT dispatch book prior to the surgery. 12) The respective wards shall be responsible for transporting the patients to and from the Maternity Operation Theatre after being informed by the OT staff. 13) The Operation Theatre guidelines for patient‟s attire shall be adhered to. 14) At the Operation Theatre “transfer bay” the ward staff shall “hand over” the patient to the theatre nurse to ensure patient‟s safety. Any special instructions shall be conveyed to the Operation Theatre nurse. 15) The Operation Theatre staff shall carry out the necessary checklist in accordance to the standard procedures. 16) The ward staff shall be informed of any cancellation of cases. 17) All OT staff and relatives accompanying patients shall abide by the rules‟ and regulations pertaining to the Operation Theatre attire. 18) Mentally handicapped and psychiatric patients may be accompanied into the Operation Theatre by a single relative who signed the operation consent. 19) No food and drinks are allowed in the OT except in the designated rest rooms. 20) The OT shall receive all their sterile supplies from CSSD. 21) All linen and instruments shall be packed in OT before being sent to CSSD for sterilization. 22) Short cycle sterilization for dropped instruments shall be carried out in the OT 23) The Operation Theatre shall be cleaned following set guidelines and procedures of the Operation Theatre. 24) The Operation Theatre shall be closed for routine cleaning for a few hours once a week 25) Existing regulations on cleaning, sterilization and disinfection as stated in the “Guidelines on control of Hospital Acquired Infections and the Disinfections and Sterilization Policy and Practice”, MOH, 1997 (Revised) shall be observed. 26) For infectious cases, the appropriate guidelines issued by the MOH to be adhered 12Department of O&G, Sarawak General Hospital
  • 13. 27) The sterility tests for air and equipment in OT and the bacteria surveillance tests shall be carried out as and when indicated.Measurable elements:  1) Cases reviewed by medical officer/registrar.  2) Cases reviewed by specialist  3) Cases reviewed by anaesthetist  4) Counselling of patients and relatives  5) Consent taken from patient  6) Blood investigations taken and reviewed by doctor  7) OT checklist  8) Sterile supplies from CSSD  9) Air sterility and bacteria sterility test in OT  10) Cleaning roster for OT  11) OT list prepared and signed by HODThe standard for all the above measurable elements shall be 100% 13Department of O&G, Sarawak General Hospital
  • 14. 2.2.1 DOCUMENTATION________________________________________________________ADMISSION CLERKING SHEET (88.H314.01)1. All columns must be filled2. Identified risk factors - write in RED3. Ensure recording of salient information - such as blood group / rhesus factor/ allergiesThe follow up notes form is designed to allow recording of information of a particularantenatal visit in a SINGLE row. Record new and current information obtained during aparticular visit.WARD NOTES:1. Each review should include complaints, findings, results, assessment, diagnosis working diagnosis and plan of management. In booked cases, this plan should be stated clearly in the notes.2. Specialist input is required in all patients with risk factors3. All entry in the case notes must include: 3.1 Date (include the year) 3.2 Time (use the 24 hour clock) 3.3 Signature and name clearly printed or stamped4. Self- inking rubber stamp is recommended (Compulsory for all house officers).5. House officers to write "H.O" below their names.6. When notes are written on behalf of others, the names of the senior doctor should head the entry 6.1 S/B: SEEN BY 6.2 D/W: DISCUSSED WITH 6.3 S/W: SEEN WITH 7. Entry on behalf of the head of department / unit should be written in red. 8. Each review should include a short note regarding the case, salient features, risk factors and working diagnosis. 9. Every patient who is admitted to the ward must have a written plan of management. 14Department of O&G, Sarawak General Hospital
  • 15. OBSTETRIC OPERATIVE NOTES:1. Completeness is the responsibility of the surgeon.2. Names of doctors should be in full.3. All notes must end with the name and signature of the person writing the notes.4. Blood loss 500ml and more must be written in red and include the term PPH .5. Post-operative orders should be tailored to the case including relevant investigations.6. HPE Forms: 6.1 Must contain a short case summary of the patient. 6.2 Specimen must be identified and described correctly. 6.3 The name of the doctor requesting the examination should be that of the Surgeon. 6.4 If the house officer writes the form, his/her name should follow that of the Surgeon. 6.5 All forms especially for specimen suspicious of malignancy must be counter checked by Specialist / Medical Officer before submission.7. Indications for LSCS should follow the standard list, (refer appendix)DISCHARGE SUMMARY:  Discharge note should be given to patient. This should contain only the diagnosis and plan of management. The proper discharge summary should be clipped to the patient‟s case note.Antenatal Ward  A patient admitted and discharged should have a discharge summary of her admission and to be clipped in her antenatal care booklet (Pink Book). It should include the date of admission, date of discharge, reason for her admission and the managementPostnatal WardIn Caesarean sections / Hysterectomies, details on:1. Indication2. Operative difficulties / complications3. Blood transfusion, if any4. Post operative recovery5. Plan for next delivery (mode)6. Any contraindication for subsequent trial of scar should be included in the Red Book/Patient Held record/Home Based Card 15Department of O&G, Sarawak General Hospital
  • 16. E-NOTIFICATIONS: 1) E-notifications for all postnatal discharge need to be done by the designated nurse in each maternity ward on a daily basis every morning. The notifications will be e- mailed to respective Divisional Health Office. The DHO will then relay this information to the respective MCH clinics within their area. The purpose of this exercise is to inform the respective clinics that their patients have delivered and home visits can be arranged and prioritized. 2) The last column on the e-notification chart should have adequate data on the plan of management for each postnatal mother. If specific home visits are required then it should be stated clearly.WEEKLY IN-PATIENT SUMMARY:Any patient managed as an in-patient for duration of five days or more should have aweekly summary. A review of such patients by the ward consultant is compulsory.  Every patient must be treated with respect and fairness  Staff should not be rude and harsh to patients and their relatives  Every patient must have a written plan of management upon discharge  A discharge note is given to the patient while a complete discharge certificate is clipped to the admission notes.  E-notification for all obstetric discharges  The patient should understand the plan of management  Appropriate counselling should be given to all patients 16Department of O&G, Sarawak General Hospital
  • 17. 2.2.2 GUIDELINES ON GENERAL SAFETY PRECAUTIONS_____________________________________________________________PROTECT YOURSELF1. Wear gloves when setting intravenous lines and handling blood specimen.2. All specimens and needles and syringes must be placed in a kidney dish when carried from place to place to avoid accidental injury3. Gown-up when conducting delivery or performing procedures4. Use disposable sterile gown / visor / goggles / boots when conducting labour in a biohazard case (positive for HBsAg / HIV).5. Use long gloves / elbow length gloves when performing MRP.6. Use of eye protection is recommended during delivery and episiotomies repair.7. Use OT garment while on duty in labour room.8. Use plastic gown during delivery.9. Use sterile gown while doing MRP.9. Report all needle prick injury and follow established protocols.10. Test yourself for Hepatitis B Antibody levels.11. Obtain immunization against Hepatitis B.PROTECT YOUR COLLEAGUE 1. Identify high-risk patients (eg. Positive for Hepatitis B) whenever a patient; is passed over during shift changes or when a patient is transferred from one station / ward to another. 2. Label all blood specimens from high-risk patients using the special biohazard stickers stamp. 3. Personally dispose all sharps (injection needles / suture needles) into the "sharps bin". Sharps should not be left unattended.PROTECT YOUR PATIENT1. Label all blood specimen bottles. The person taking blood must label all specimen tubes correctly.2. Wash your hands before and after examination of patients.3. In the labour room, wear a mask before doing vaginal examination.4. Swab the vulva with sterile water before doing a vaginal examination.5. Drape (sterile) patient before delivery.6 Use aseptic techniques to insert a Foleys catheter.7. Use prophylactic antibiotics where applicable (eg. MRP )8. Use sedation / local or general anaesthesia appropriately 8.1 Local anaesthesia (episiotomies ) 8.2 Pudendal block (instrumental delivery). 8.3 Manual removal of placenta (MRP) should be performed in OT. 17Department of O&G, Sarawak General Hospital
  • 18. 9. ALL OR NONE LAW‟. The doctor who conducts the delivery is expected to see the patient through till the end (till the episiotomy wound is repaired). This should also be strictly followed in instrumental deliveries and Caesarean sections.10. Doctors and nurses performing procedures or suturing the perineum /episiotomy MUST complete the procedure and not ask another staff to complete the procedure unless he or she is unable to complete the procedure due to technical difficulties.11. Doctors and nurses who are unable to complete a procedure due to difficulties must obtain help from someone more experienced or senior. A House Officer should not ask another House officer to take over.12. Inform patient of relevant details of current pregnancy, which may have a bearing upon management of her future pregnancy (eg. Extended tear of uterus during LSCS). This information should be reinforced once again to both couple upon discharge.13. Details of such complications must be documented (in red pen) in the patient held card / Red Book.14. All staff must follow available standard operating procedures and guidelines when performing various work processes in the labour ward15. Available CPG related to O&G practice needs to be followed16. Obstetric drills should be carried out regularly in the labour wardPROTECT THE DEPARTMENT1 Commence partogram recording as soon as patient is in established labour.2. Be aware of standing orders, ward procedures and evidence based clinical practice guidelines.3. Call for help whenever necessary as: 3.1 you may need an extra pair of hands; 3.2 a senior may be more competent to handle the situation; 3.3 a witness can attest that you are taking the appropriate action.4. Use “RED ALERT" team when appropriate.5. Counsel the patient regarding progress, line of management and intended procedure. Whenever feasible, counsel the husband next of kin.6. Clear documentation of all steps taken in management including counseling.7. All morbidities, mortalities, potential medico-legal cases must involve the consultant of the ward.8. Loose talk increases risk of litigation. This is discouraged at all times.9. All patients are to be treated with care and politeness.10. Shouting at patients in labour in any situation is not acceptable. 18Department of O&G, Sarawak General Hospital
  • 19. HUSBAND FRIENDLY INITIATIVE: 1. It is a policy of the Ministry of health to promote Husband Friendly when the patient is in active labour. This is more practical when there are individual delivery suites or rooms 2. The husband should be offered to stay with his wife during labour 3. Husband should not enter or leave the delivery suite unescorted 4. Allow one person at each time to be with the patient during labour (husband or a close relative) 5. Husband can observe normal vaginal deliveries but should leave the room during instrumental deliveries or if there is an obstetric emergency 6. Video taking is prohibited 7. NO LOOSE TALK PLEASE!  ALL STAFF HAVE TO FOLLOW THE APPROPRIATE STANDARD OPERATING PROCEDURES AND AVAILABLE GUIDELINES WHEN PERFORMING THEIR RESPONSIBILITIES AND DUTIES 19Department of O&G, Sarawak General Hospital
  • 20. 2.2.3 MINISTRY OF HEALTH - COLOR CODING FOR LEVEL OF OBSTETRIC RISK ____________________________________________________ White Low risk cases; level of care -PHN/JM in Health Clinic / Klinik Desa Green Level of care - MO in Health Clinic Yellow Urgent referral to hospital with OBGYN specialist/FMS in health clinic within 48 h Red Urgent admission to the hospitalCODE WHITE: Low risk, suitable for delivery at Alternative Birthing Center (ABC)______________________________________________________________________ 1. Gravida 2 - 5. 2. No past obstetric complication(s). 3. No past medical complication(s). 4. No antenatal complication in this pregnancy. 5. Height >145cm. 6. Age 18-40 years. 7. POA 37-41 weeks. 8. Estimated fetal weight 2-3.5kgCODE WHITE: Low risk, but for hospital delivery____________________________________________________________________ 1. Primigravida 2. Age < 18 years or > 40 years 3. Gravida 6 or above should deliver in specialist hospitals (e.g. SGH) 4. Birth interval < 2 years or > 5 years 5. Associated problems 5.1 height < 145cm 5.2 Single mother 20Department of O&G, Sarawak General Hospital
  • 21. CODE GREEN: Refer to Family Medicine Specialist or MO______________________________________________________________________1. Rhesus negative.2. Mothers pre-pregnancy weight or weight at booking <45kg.3. Associated medical complications including psychiatry & physical disability.4. Previous gynaecological surgery.5. Drug addiction / smoking.6. Unsure of LNMP.7. History of 3 consecutive miscarriages.8. Past obstetric history of: 8.1 Previous caesarean section. 8.2 Past history of PIH / eclampsia / diabetes. 8.3 Perinatal death. 8.4 History of babys birth weight <2.5kg or >4kg. 8.5 3rd degree perineal tears. 8.6 Retained placenta. 8.7 PPH. 8.8 Instrumental delivery. 8.9 Prolonged labour.9. Multiple pregnancies.10. High BP (>140/90 mmHg) without proteinuria.11. Hb<llgm%.12. 2 episodes of glycosuria.13. Proteinuria > 1+.14. Excessive weight gain >2kg in a week.15. Weight >80kg.16. SFH<or>POA/POG.17. Malpresentation at 36 weeks.18. Head not engaged at 37 weeks in a primigravida. CODE YELLOW: Refer to FMS / hospital with OBGYN Specialist / nearest hospital (within 48 hours) ______________________________________________________________________ 1. Mother with positive HIV status. 2. Mother with Hepatitis B positive. 3. BP 140/90 to 160/110 mmHg, without proteinuria. 4. Diabetic mother. 5. Reduced fetal movements at POA / POG >32 weeks. 6 POA/POG>41 weeks. 21Department of O&G, Sarawak General Hospital
  • 22. CODE RED: Urgent admission to hospital_____________________________________________________________________1. Eclampsia.2. Pre-eclampsia (high BP with proteinuria) or symptomatic / impending eclampsia or BP> 160/110 mmHg.3. Heart disease and symptomatic.4. Dyspnoea on exertion.5. Uncontrolled diabetes (glycosuria brick red) with ketonuria (>l+)6. APH (including miscarriage)7. Abnormal fetal heart rate: 7.1 FHR<110/min >26/52. 7.2 FHR>160/min >34/52.8. Symptomatic anemia at any POA / POG.9. Premature uterine contractions.10. PPROM/ PROM.11. Severe asthmatic attacks. 22Department of O&G, Sarawak General Hospital
  • 23. 2.2.4 CONSENT FOR CAESAREAN SECTION_____________________________________________________1. Informed consent should be obtained prior to surgery.2 To be obtained preferably by the doctor who makes the decision / or the surgeon.3. Review the patients medical notes.4. Explain the indication and the procedure to the patient and document clearly in the case notes.5 The patient must be informed of the general risks associated with the operation, while stressing the benefits.6. If a patient refuses to consent, the discussion with the patient should be clearly documented in the medical notes. The case should subsequently be referred to the specialist in charge.7. If a patient is unconscious, informed consent should be obtained from the next of kin (preferably, the husband).  Ensure the indication and information provided to the patient is clearly documented in her admission notes  Consent for tubal sterilization should be taken by the surgeon and clearly written 23Department of O&G, Sarawak General Hospital
  • 24. 2.2.5 PROPHYLAXIS FOR ACID ASPIRATION IN CAESAREAN SECTIONS______________________________________________________1. Generally the use of regional anaesthesia like spinal and epidural will greatly reduce the risk of acid aspiration. It is the preferred method for most cases of caesarean sections.2. When general anaesthesia is used, the use of cricoid pressure (Sellicks manouev er) and rapid sequence induction are effective ways to prevent reflux of gastric contents.3. Whenever anaesthesia is given to a pregnant patient, skilled assistance must be available for the anaesthetist.4. A drill for "failed intubation" should form part of the training for any doctor administering anaesthesia to the pregnant patient.5. The use of clear oral antacids is effective in raising the pH of gastric secretions.6. Routine preoperative use of H 2 receptor antagonists is justified as it effectively reduces gastric fluid volume. When administered intravenously, care should be taken to administer the dose over 5 to 10 minutes to avoid the potential for hypotension especially with Cimetidine. The use of (5) and (6) does not however guarantee against aspiration, except that it reduces the severity of the pneumonitis.7. Metoclopromide given IV l0mg/dose may be useful as a prophylactic by increasing lower oesophageal sphincter tone.8. The use of nasogastric tube to empty gastric content should be avoided.9. Suggested schedule for the administration of pharmacological agents in the prophylaxis for acid aspiration 9.1 Elective Caesarean Section 9.1.1 Ranitidine 150 mg or Cimetidine 400mg orally the night before surgery. 9.1.2 Ranitidine 150 mg or Cimetidine 400mg orally on the day of surgery, preferably 2 hours or more before surgery. 9.1.3 Sodium Citrate (0.3 molar) 30ml orally before leaving for the theatre. 9.2 Emergency Caesarean Section 9.2.1 IV Ranitidine 50mg or IV Cimetidine 200mg as soon as the decision is made for Caesarean section. The drug should be administered over10 minutes by the staff nurse. 9.2.2 Oral Sodium Citrate solution (0.3 molar) 30ml orally before leaving for the theatre. 9.2.3 IV Metoclopromide l0mg may also be administered at the same time as Ranitidine or Cimetidine. This is however optional. 24Department of O&G, Sarawak General Hospital
  • 25. 2.2.6 ULTRASOUND SCAN DURING LABOUR_______________________________________________________________________ 1. Unsure of dates 2. Suspected malpresentation 3. APH - to exclude placenta praevia 4. Confirmation of intrauterine death 5. Fetal viability in abruption of placenta 6. Multiple gestations - to confirm presentation 7. Preterm labour, preferably by TVS for assessment of cervical length 8. Suspected macrosomia baby 9. Obese patient - difficulty in locating fetal heart activity 10. Previous uterine scar - for placental localization (if not done before labour) 11. Confirm type of breech presentation (difficult for untrained doctor) 25Department of O&G, Sarawak General Hospital
  • 26. 2.2.7 THROMBOPROPHYLAXIS IN PREGNANCY______________________________________________________ 1. Thromboembolism remains a preventable cause of maternal deaths 2. Pregnancy is a hypercoagulable state 3. Increased in factor VIII, IX, X, fibrinogen 4. Decreased fibrinolytic activity, anti-thrombin and protein S fall 5. Venous stasis in pregnancy 6. Pregnancy increases risk to 6 folds (from first trimester till 6 weeks post-partum) 7. Caesarean sections further increases the risk approximately by 10-20 folds2.2.7.1 THROMBOPROPHYLAXIS GUIDELINES IN VAGINAL DELIVERYLOW RISK:Assessment Uncomplicated pregnancyTherapy Early mobilization Avoidance of dehydrationMODERATE RISK:Assessment Any 2 of these factors: 1. Age >35 years 2. Obesity >80kg at booking 3. Parity >4 4. Labour >12 hours 5. Gross varicose veins 6. Current infection 7. Pre-eclampsia 8. Immobility prior to labour for >4 days 9. Mid-cavity or rotational forceps delivery 10. Major current medical illnessTherapy S/C Enoxaparin 40mg daily or S/C Tinzaparin 0.45mls (50-90Kg) or S/C unfractionated Heparin 5,000iu BD Where heparin is contraindicated, use graduated elastic compression Stockings.Commence After at least 6 hours post-delivery (allow 3 hours between removal of the epidural cannula and first administration) 26Department of O&G, Sarawak General Hospital
  • 27. Duration Should continue until discharge  If discharged prior to day 7, discontinue therapy  If hospital stay continues beyond day 7, the indication needs to be reviewed by medical officer or specialist.HIGH RISK:Assessment: Any vaginal delivery with any 1 of these factors: 1. Patient with >4 moderate risk factors 2. Extended major pelvic or abdominal surgery 3. Patient with family history of DVT / pulmonary embolism or 4. Thrombophilia 5. Paralysis of lower limbs 6. Patient with anti-phospholipid antibody or lupus anticoagulantTherapy: S/C Enoxaparin 40mg daily or S/C unfractionated Heparin 7,500-10,000iu BD plus graduated elastic compression stockingsCommence: Within 6 hours (allow 3 hours between removal of the epidural cannula and first administration)Duration: Should continue until discharge Patients with a past history of venous thromboembolism or underlying thrombotic problem, should continue the therapy for a minimum of 6 weeks .Specialist advices should be sought for those with a family history of thrombophiliaHeparin and warfarin are not contraindicated in breastfeeding. 27Department of O&G, Sarawak General Hospital
  • 28. 2.2.7.2 THROMBOPROPHYLAXIS GUIDELINES FOR CAESAREANSECTION(This guideline applies to all pregnant women delivered by Caesarean section)ALL women who had caesarean section should be given low molecular weightheparin (LMWH) /Unfractionated heparin unless contraindicated. Dosage: Antenatal and postnatal prophylactic dose of LMWH Weight (kg) Enoxaparin Tinzaparin (Clexane) <50 20mg daily 3500 units daily 50-90 40mg daily 4500 units daily 91-130 60mg daily 7000 units daily 131-170 80mg daily 9000 units daily >170 0.6mg/kg/day 75 units/kg/day  Heparin: Subcutaneous 5000 units every 12 hourly (for patient who are uncomfortable with porcine-based LMWH)  Alternative: Fondaparinux (subcutaneous 2.5mg daily) can be considered for women intolerant of heparin compound. Timing:  Should be started 6 hours after delivery and given till discharged from ward or for 7 days if high risk or still admitted in the ward, provided that there is no postpartum haemorrhage (PPH).  High Risk patients should continue with LMWH for 7 days even after discharge  Those with PPH should be fitted with TEDS/Venaflow. (if available) Contraindications: LMWH should be avoided or postponed in women who are at high risk of bleeding after careful consideration of the balance of risk of bleeding and clotting. Risk factors for bleeding are: Women with active APH or PPH Women considered at increased risk of major PPH Bleeding diathesis Thrombocytopenia (Platelet <75x 109) Acute stroke in last 4 weeks (ischaemic or haemorrhagic) Severe renal disease (GFR <30 ml/minute/1.73m2) Severe liver disease (prolonged PT or known varices) Uncontrolled HPT (SBP>200mmHg, DBP>120mmHg) 28Department of O&G, Sarawak General Hospital
  • 29. General Advice:  All patients should be advised to use „thromboembolic deterrent stoking‟ (TEDs) for 6 weeks after caesarean section. (may not be available in districts)  MOs should ensure all patients are adequately hydrated and encouraged to ambulate early whilst in the ward.  Adequate post-operative pain relief is recommended to aid in early ambulation  Consult the O&G specialist on-call when necessary  Upon discharge, all patients must be counseled to ambulate and drink adequately.  They must seek medical attention early if they experience symptoms suggestive of venous thromboembolism (VTE) such as shortness of breath, palpitation, chest pain, fever, calf/thigh pain/swelling or if they generally feel unwell.2.2.7.3 THROMBOPROPHYLAXIS GUIDELINES IN PREGNANCY ANDPUERPERIUM1. Women with a previous history of venous thromboembolism and no other knownthrombotic risk factorsSuch patients require prophylaxis at least during-postpartum period:1.1 Within 12 hours of delivery, introduce (or reintroduce) S/C Heparin 7,500- 10,000 iu BD.1.2 And 24-48 hours after delivery, commence warfarin.1.3 Continue Heparin until INR is 2.0-2.51.4 Anticoagulation should continue 6-12 weeks.1.5 Some women may prefer to continue S/C Heparin (7,500-10,000 IU BD) instead of warfarin, however the risk of osteoporosis should be considered.1.6 Where anticoagulants are contraindicated, graduated elastic compression stockings worn for 6-12 weeks following delivery may be effective.2. Women with a previous thrombotic event during pregnancy and no otherknown risk.2.1 Such women should consider antenatal thromboprophylaxis, commencing 4-6 weeks ahead of the gestation stage at which the previous thrombosis occurred.2.2 S/C Heparin 5000iu BD and / or2.3 Graduated elastic compression stockings or2.4 Clinical (+/- radiological) surveillance for evidence of thromboembolism may be considered. 29Department of O&G, Sarawak General Hospital
  • 30. 3. Women with a known heritable thrombophilic defect eg. deficiency of anti- thrombin (AT), protein C (PC) or protein S (PS); activated protein C resistance; whether or not they have had a previous thrombosis. 3.1 Such women usually merit referral to a unit experienced in managing pregnancy in thrombophilic women. 3.2 These women require thromboprophylaxis at least during postpartum period as outlined earlier. 3.3 Many women with thrombophilic defects in addition, merit antenatal thromboprophylaxis. 3.4 The timing of introduction and the dose of anticoagulant must be decided on an individual basis, aiming to minimize the total exposure to heparin. 3.5 For PC and PS deficient women, S/C Heparin 7500-l000iu BD, or LMWH commencing late 2nd or early 3rd is appropriate. 3.6 Women with certain type of AT deficiency are at high risk of pregnancy-associated thrombosis. In these women, thromboprophylaxis usually requires S/C Heparin in doses adjusted to achieve a plasma heparin concentration of 0.2 - 0.4 iu/ml. These women in particular usually merit referral to a unit experienced in managing pregnancy in thrombophilic women.4. Women with an acquired thrombophilic defect eg. Antiphospholipidantibodies (lupus anticoagulants or anticardiolipin antibodies).4.1 Those who have already had a thrombotic event should be managed as outlined in 14.2 Those who have had no previous thrombotic event may merit at least postpartum thromboprophylaxis as outlined in 1.5. Women with no past history of thrombosis and no known thrombophilic defect, butwith other thrombotic risk factors particularly where these risk factors occur incombination, eg: a) Age >35 years b) Caesarean section, particularly if carried out as an emergency procedure c) Obesity d) Immobilization, >4 days bed rest e) Pre-eclampsia f) Concurrent infection g) Parity > 4 h) Extended major surgery eg. Caesarean hysterectomy i) Medical conditions eg nephritic syndrome 5.1 Postpartum thromboprophylaxis should be considered 5.2 A LMWH may be considered in women who have heparin-induced thrombocytopenia; however, cross-reactivity should be excluded. 30Department of O&G, Sarawak General Hospital
  • 31. 2.2.7.4 GUIDELINES FOR EPIDURAL ANAESTHESIA IF THEPATIENT IS ON THROMBOPROPHYLAXISHeparin 1. Wait 4 hours after giving dose before setting block or removing catheter 2. Next dose no less than 2 hours after giving block.LMWH 1. Wait 10-12 hours after dose before inserting block or removing catheter. 2. Next dose no less than 6 hour later 3. Beware of other anticoagulant / NSAIDs which may increase risk.In all patients, extreme vigilance is required to detect new numbness,weakness or bladder / bowel dysfunction.Any neurological problem must be investigated as an emergency. 31Department of O&G, Sarawak General Hospital
  • 32. 2.3 PROBLEMS IN PREGNANCY2.3.1 PIH/PE1.3.4 Antihypertensive therapy 1.3.4.1 Hydralazine Infusion Regime 2.3.2.2 Labetalol Infusion Regime1.3.5 Eclampsia 1.3.5.1 Magnesium Sulphate Regime 1.3.3.2 Diazepam Regime2.3.11 HELLP Syndrome2.3.12 Cardiac Disease in Pregnancy2.3.13 Bronchial Asthma in labour2.3.14 Diabetic mother in labour2.3.15 Rhesus negative mother2.3.16 HIV in pregnancy2.3.17 Breech/ECV2.3.11 Twins in labour2.3.12 Trial of scar2.3.13 Intrauterine death 32Department of O&G, Sarawak General Hospital
  • 33. 2.3.1 PREGNANCY INDUCED HYPERTENSION (PIH/PE)______________________________________________________ Low dose aspirin is now recommended to be given to women with the following history:  Hypertensive disease in previous pregnancies  Chronic renal disease  Autoimmune disease like SLE, anti-phospholipid syndrome  Type 1 or 2 diabetes  Chronic hypertension Daily low dose aspirin 75mg (1/4 tab of 300mg tablets) to be given to antenatal mothers from 12 weeks onwards till 36 weeks or till deliveryTIMING OF DELIVERY: Timing of delivery for antenatal mothers with PRE-ECLAMPSIA (PE) is by 37 weeks POA Timing for delivery for antenatal mothers with PIH on anti-hypertensive is by 38-39 weeks POA (depending on cervical favourability) Timing of delivery for PIH not on anti-hypertensives by 40 weeks POA Patients with severe PIH/PE should be given IM 5GM of Magnesium Sulphate in each buttock before being transferred to a aspecialist hospital 33Department of O&G, Sarawak General Hospital
  • 34. 2.3.2 ANTIHYPERTENSIVE THERAPY_______________________________________________________________________________________Indication: 1. Severe hypertension (160/110minHg) and symptomatic (MgSO4 as well) 2. Mean arterial pressure (MAP) >125 mmHg or 2 consistent readings of >160/110mmHg, 15 minutes apart if asympromatic* Refer table in the protocol -> Rapid control -> Maintenance -> Infusion drip set -> Infusion syringe pumpAim:1. To stabilize diastolic pressure between 90-100 mmHg (do not reduce DBF below 90mmHg)2. Use of infusion syringe pump is preferred (to avoid fluid overload)Maternal and fetal monitoring:1. PR/BP (manual) every 15 minutes2. Hourly after BP has been stabilized3. Continuous CTG till BP is stabilized (provided POA is above 28 weeks)Investigations:1. FBC2. PT/APTT3. Renal profile (+ serum uric acid)4. LFT5. GSH/GXM blood (KIV LSCS)6. Urine FEME and C&S2.3.2.1 ANTIHYPERTENSIVE THERAPY -PARENTERAL HYDRALLAZINE 1. NEPRESSOL1 ampoule = 25mg/2mlRapid Control 1. Dilute 1 ampoule of nepressol with 8 ml of water, so 1ml = 2.5mg. 2. Give 2ml/ 5mg slow bolus. 3. Can repeat every 20 minutes up to a maximum of 2 doses, if DBP ≥ 110mmHg, to start infusion. 34Department of O&G, Sarawak General Hospital
  • 35. Maintenance a. Via infusion syringe pump 1. Nepressol 50mg (2 amp = 4ml) + 46ml Normal saline = 1ml/1mg 2. Start at 1ml/hour (1mg/hour) 3. Increase every 20 minutes by 1 ml up to a maximum of 10ml/hour b. Via IV drip infusion 1. Nepressol 50mg (2 amp =4ml) + 500ml Normal saline = 10ml/1mg 2. Start at 15ml/hour (1.5mg/hour) 3. Increase every 20 minutes by 10 ml up to a maximum of 100ml/hour 2. APRESOLINE1 ampoule = 20 mgRapid Control 1. Dilute 1 ampoule with 8 ml of water, so 1ml = 2mg. 2. Give 2.5ml/ 5mg slow bolus. 3. Can repeat every 20 minutes up to a maximum of 2 doses, if DBP ≥ 110mmHg, to start infusion.Maintenance a. Via infusion syringe pump 1. Apressol 50mg (2 1/2amp = 5ml) + 45ml Normal saline = 1ml/1mg 2. Start at 1ml/hour (1mg/hour) 3. Increase every 20 minutes by 1 ml up to a maximum of 10ml/hour b. Via IV drip infusion 1. Apressol 50mg (2 1/2 amp =5ml) + 500ml Normal saline = 10ml/1mg 2. Start at 15ml/hour (1.5mg/hour) 3. Increase every 20 minutes by 10 ml up to a maximum of 100ml/hour2.3.2.2 ANTIHYPERTENSIVE THERAPY – PARENTERAL LABETOLOL1 ampoule = 25mg/5mlRapid Control 1. Give 1 ampoule slow bolus. 2. Can repeat every 20 minutes up to a maximum of 2 doses, if DBP ≥ 110mmHg, to start infusion. 35Department of O&G, Sarawak General Hospital
  • 36. Maintenance a. Via infusion syringe pump 1. 50mg (2 amp = 10ml) + 40ml Normal saline = 1ml/1mg 2. Start at 20ml/hour (20mg/hour) 3. Increase every 30 minutes by 20 ml up to a maximum of 160ml/hour b. Via IV drip infusion 1. 200mg (8 amp =40ml) + 160ml Normal saline = 1ml/1mg 2. Start at 20ml/hour (20mg/hour) 3. Increase every 30 minutes by 20 ml up to a maximum of 160ml/hourContraindications to Labetolol: 1. Bronchial asthma 2. Congestive heart failure (CCF) 3. AV heart block 36Department of O&G, Sarawak General Hospital
  • 37. 2.3.3 ECLAMPSIA_______________________________________________________ 1. Call for help! 2. ABC 3. Secure IV at least 2 IV lines. 4. Abort seizure with loading dose of IV/IM MgSO4 then to start on maintenance dose (repeated bolus dose may be necessary). 5. Monitoring in HDU labour ward/ICU 6. Start parenteral anti- hypertensive if DBP ≥ 110mmHg or MAP > 125 mmHg 7. Monitoring according to protocol. 8. Total fluid 2L/24 hours (83ml/hour) 9. Monitor fetus 10.Plan for delivery after patient is stabilised – timing and mode 11.If repeated eclampsia, to refer to anaesthetist for intubation and cerebral resuscitation in ICU2.3.3.1 MAGNESIUM SULPHATE REGIME1 ampoule = 2.47gm/5mlLOADING DOSEIntravenous 1. 4gm (8ml) MgSO4 + 12ml Normal Saline or H2O given over 15 minutes 2. Further convulsion after 15 minutes: 3. 2gm (4ml) + 8ml Normal Saline given over 15 minutesIntramuscular 1. 10gm with 5gm(10ml) given at each buttockMAINTENANCE DOSEIntravenous 1. 24.7gm (10 ampoules) + 500ml Normal Saline to run at 21ml/hour = 1gm/hourIntramuscular 1. 5gm (10ml) deep im in alternate buttock every 4 hours 2. Maintenance dose to continue up till 24 hours post-delivery or 24 hours from the last convulsions (whichever occurs later) 37Department of O&G, Sarawak General Hospital
  • 38. ANTIDOTE FOR MGSO4 TOXICITY  1gm Calcium gluconate (10ml of 10% solution) given IV slow bolus over 3 min.  If level of Mgnesium is > 3.5 mmol/L, cease infusion and consult ObstetricianMonitoring of patient on MgSO41. BP/PR every 15 minutes – 30 minutes2. Respiratory rate hourly, must be > 16/min3. Patellar reflex/knee jerk hourly (record as Absent, Normal or Brisk)4. Urine output hourly more than 100mls/4 hour5. Pulse oxymeterManagement of potential magnesium sulphate toxicity:1. Urine output < 100ml/ 4hour: a) Check reflexes and respiratory rate (ensure no signs of toxicity) b) Send BUSE, S. creatinine and serum magnesium level stat and trace results. i. If serum creatinine is normal and magnesium level is within therapeutic range then continue same maintenance dose ii. If serum creatinine is normal and magnesium level is raised above therapeutic range, reduce the dose by half to 0.5mg/hour iii. If serum creatinine is raised or serum magnesium level is above the therapeutic range then STOP the infusion c) If unable to do serum magnesium levels, send BUSE and serum creatinine but reduce the maintenance dose to 0.5mg/hour d) Listen to lungs & review fluid balance: KIV fluid challenge of 500mls N/S over 1hour and monitor urine output e) Once urine output improves, the maintenance dose should be resumed at 1mg/Hr2. Absent patellar reflex: a) Stop infusion till reflexes return b) May consider restarting infusion at lower dose when reflexes return c) Send blood for BUSE, S Creatinine and if available check serum magnesium level3. Respiratory depression: a) Stop infusion b) Maintain airway, nurse patient in recovery position c) Slow IV bolus of 1gm calcium gluconate 38Department of O&G, Sarawak General Hospital
  • 39. 4. Respiratory arrest: a) Stop infusion b) Intubate and ventilate (till return of spontaneous respiration) c) Slow IV bolus of 1gm calcium gluconate# Serum magnesium levels should be checked routinely in patients at very high risk ofeclampsia or had eclamptic fit to ensure that the levels are within therapeutic rangeMg Conc Effects(mmol/L)0.8 to 1.0 Normal plasma level1.7 to 3.5 Therapeutic range2.5 to 5.0 ECG changes (P-Q interval prolomged, widen QRS complex)4.0 to 5.0 Reduction in deep tendeon reflexes> 5.0 Loss of deep tendon reflexes> 7.5 Sinoatrial and atrioventricular blockade, respiratory paralysis and CNS depression> 12 Cardiac arrest2.3.3.2 DIAZEPAM REGIME 1. Diazepam is no longer the drug of choice for the management of eclampsia 2. It can still be used if magnesium sulphate is not available 3. Give slow bolus of IV diazepam 10 mg over 5 minutes 4. Repeat 10mg diazepam by low bolus if convulsions still persists (refer to appendix 3.4) 39Department of O&G, Sarawak General Hospital
  • 40. 2.3.4 HELLP SYNDROME______________________________________________________HELLP Syndrome is a subset of patient with pre-eclampsia/ eclampsia with biochemicalevidence of hemolysis, elevated liver enzyme and low platelet countsIt is a potentially lethal condition which will improve following the delivery of the fetus.However beware that the disease process reaches its nadir 24 to 48 hours after delivery.This condition needs to be differentiated for thrombotic thrombocytopenic purpura.Diagnosis of HELLP SyndromePatient presents with:1. Severe pre-eclampsia or eclampsia2. Hemolysis3. Hepatic dysfunction. Elevation of: 3.1 Lactate dehydrogenase (LDH) 3.2 Indirect bilirubin 3.3 Aspartate amniotransferase (AST)4. Thrombocytopenia Severity of HELLP is based on platelet count Class 1 <50,000/uL Class 2 <100,000/uL Class 3 <150,000/uLPatient with HELLP syndrome has a wide pulse pressure: systolic hypertension > 140mmHg and diastolic pressure < 90 mmHg. Clinical findings of pre-eclampsia such asdiastolic hypertension, proteinuria and non-dependant oedema may not be present.Diagnosis at times is made after delivery (20%).Management of HELLP Syndrome1. Assessment and evaluation of patient 1.1 Full blood count 1.2 Coagulation profile 1.3 Peripheral blood film 1.4 Electrolyte 1.5 Uric acid 1.6 Renal profile 1.7 Liver function test , indirect & total bilirubin 1.8 Urine2. Assessment of fetus3. Plan for delivery - timing and mode4 Control of blood pressure5 Prevention of seizure - use of MgSO4 40Department of O&G, Sarawak General Hospital
  • 41. 2.3.5 CARDIAC DISEASES IN PREGNANCY______________________________________________________IntroductionCardiovascular diseases are encountered in 0.5 - 4.0% of pregnant women. The commondisorders are rheumatic valvular disease, congenital heart disease and cardiomyopathy.Cardiac disease remains the commonest non-obstetric cause of maternal mortality in Malaysia,accounting for 10% of all maternal deaths in 1996. Early detection, adequate counseling andappropriate management are important to improve maternal and fetal outcomes.Pre-pregnancy assessment is an important tool in reducing maternal mortality due to heartdiseases. Besides postpartum haemorrhage, complications arising from heart diseases are the commonest cause of maternal deaths in Sarawak over the last few years!Management Principles1. Pre-conceptual counseling2. Assessment and stratification of maternal and fetal risks. 2.1 General health assessment 2.2 Determine functional class 2.3 Confirm clinical diagnosis 2.4 Establish baseline haemodynamics 2.5 Minimize aggravating factors of cardiac condition, including correction of anaemia if any.3. Management of the pregnancy and complications of cardiac disease.4. Determine the timing, mode and place of delivery.5. Antibiotic prophylaxis during procedures / labour.Risk assessment and stratification:Maternal and fetal risk assessment is based on the following: 1. NYHA Functional Class. The maternal prognosis is strongly related to NYHA functional class prior to pregnancy, with maternal mortality varying from <1% in NYHA 1 or II to around 7% in those with NYHA 111 or IV. 41Department of O&G, Sarawak General Hospital
  • 42. The classification is as below:CLASS I No limitation. Ordinary physical activity does not cause undue fatigue. dyspnoea or palpitation.CLASS II Slight limitation of physical activity. Such patients are comfortable at rest. Ordinary physical activity results in fatigue, dyspnoea or angina.CLASS III Marked limitation of physical activity. Although patients are comfortable at rest, less than ordinary activity will lead to symptoms.CLASS IV Inability to perform any physical activity without discomfort. Symptoms of congestive failure are present at rest. Increased discomfort : is experienced with any physical activity.2. Presence of cyanosis.3. Left ventricular and right ventricular function.4. Severity of pulmonary hypertension.5. Presence of valve / conduit stenosis (left heart obstruction)6. Presence of conduction defects.7. Presence of arrhythmias8. Smoking.9. Multiple gestations. Mortality risk associated with pregnancy: GROUP I / LOW RISK (Mortality < 1 %) 1. Atrial septal delect 2. Ventricular septal defect 3. Patent ductus arteriosus 4. Pulmonic / tricuspid disease 5. Aortic and mitral regurgitation 6. Mitral stenosis, NYHA class I and II. 7. Corrected Tetralogy of Fallot 8. Acyanotic Ebsteins anomaly 9. Hypertrophic cardiomyopathy 10. Porcine valve 42Department of O&G, Sarawak General Hospital
  • 43. GROUP II / MODERATE RISK (Mortality 5-15%)1. Mitral stenosis with atrial fibrillation.2. Artificial valve on anticoagulation3. Mitral stenosis, NYHA class III and IV.4. Aortic stenosis5. Coarctation of aorta, uncomplicated.6. Uncorrected tetralogy of Fallot7. Previous myocardial infarction8. Marfans syndrome with normal aorta.9. Uni-ventricular circulation after Fontan operationGROUP III / HIGH RISK (Mortality 25-50%1. Pulmonary hypertension (pulmonary pressure >75% of systemic pressure)2. Eisenmengers syndrome3. Coarctation of aorta, complicated4. Severe aortic stenosis (peak gradient >64mmHg)5. Severe mitral stenosis6. Poor left ventricular function (LVEF <40%) irrespective of etiology7. Marfan s syndrome with aortic involvement (aortic root diameter >40mm)Impaired maternal functional class, smoking and the presence of cyanosis are associatedwith poor fetal outcomes.Note: A. The experience in Sarawak of women with mechanical valves is rather poor, resulting in several maternal deaths or stroke. The recommendation for the management of such patients should include appropriate counseling with regards to risks and offer termination of pregnancy to patients who do not want to continue with the pregnancy. B. The teratogenic risk of warfarin on the fetus is small at less than 2% but even smaller if the dose of warfarin is less than 5mg/day. Clexane/Tinzaparin (LMWH) is not recommended to be used in women with mechanical valves as the actual dose required cannot be monitored in SGH currently. If the patient is not keen to continue on warfarin then she should be given heparin (perhaps by subcutaneous injections) until 12-13 weeks then revert back to warfarin. A planned LSCS at 38 weeks should be planned. 43Department of O&G, Sarawak General Hospital
  • 44. C. All women with heart diseases should be counseled and assessed appropriately in early pregnancy. Decision should be made with regards to the option for termination of pregnancy and if to continue with the pregnancy then an appropriate plan of management with combine care is compulsoryLabour and Delivery:Favourable outcome is associated with a multidisciplinary team approach involving thecardiologist, obstetrician, anaesthetist and pediatrician. Complications are best avoidedby active intervention starting early in the third trimester. All antenatal mothers with heart disease should be managed in specialist hospitals and seen at the combine clinic. All should deliver in specialist hospitals! Timing and mode of delivery: 1. Routine elective admission to SGH at 34 weeks for Eisenmenger‟s patient 2. The timing and mode of delivery should be individualized after discussion with the specialist physician and obstetrician. High risk patients should be delivered at a tertiary center. 3. Spontaneous labour is preferred to induction. 4. The second stage of labour should not be allowed to be prolonged. 5. Although vaginal delivery is generally advocated in these patients, good arguments can be made for planned Caesarean section in high risk situations. 6. All patients should be given supplemental oxygen and encouraged to lie in the lateral position to avoid caval compression. 7. Patients with mechanical valves on anticoagulation with warfarin should ideally have elective caesarean sections at 38 weeksMonitoring:MotherCareful haemodynamic monitoring throughout labour and for several days postpartum isrequired. This includes: 1. Continuous ECG monitoring to detect arrhythmias. 2. Arterial saturation by pulse oximetry. 3 Blood pressure (intra-arterial in selected cases). 4 Occasionally, central venous pressure measurements may be required. 5. The use of Swan-Ganz catheter is not routinely recommended.FetalCTG Monitoring 44Department of O&G, Sarawak General Hospital
  • 45. Analgesia:Pain causes sympathetic stimulation resulting in undesirable haemodynamic changes.Thus, effective analgesia is of prime importance. Available techniques include:1.Epidural analgesia - technique of choice. Systemic hypotension should be avoided.2.Parenterai opiods, eg. IV PC A fentanyl or intermittent EM Pethidine.3.Inhalational analgesia (entonox).4.Local infiltration or pudendal nerve block for assisted delivery during second stage.5 Newer techniques such as combined spinal epidural (CSE). Antibiotic prophylaxis: Following uncomplicated vaginal deliveries, routine antibiotic prophylaxis is only recommended for patients with prosthetic heart valves and surgically constructed systemic to pulmonary shunts.StandardAmpicillin IV or IM Ampicillin 2.0gm + IV or IM Gentamicin 1.5mg/kg bodyGentamicin weight (not to exceed 80mg) 30 minutes before procedure, followedAmoxicillin by > Amoxcillin l.5gm orally 6 hours after initial dose or Repeat parenteral regime 8 hours after initial dosePenicillin Allergic PatientVancomycin IV Vancomycin 1.0 gm over 1 hour + IV or IM Gentamicin 1.5mg/kgGentamicin body weight (not to exceed 80mg) 1 hour before procedure and repeat 8 hours laterAlternative Low Risk Regime Amoxicillin 3gm orally 1 hour before procedure, then l.5gm 6 hours later Postpartum: Most patients with cardiac disease have an uncomplicated delivery and puerperium. However, the increase in venous return following delivery may result in worsening cardiac failure in patients with stenotic valves and impaired LV function. In addition, patients with Eisenmengers Syndrome and pulmonary hypertension usually decompensate in the early postpartum period. Thus, careful haemodynamic monitoring is important in these patients for about 48 - 72 hours. These patients should ideally remain in hospital for at least a week. Breast Feeding: Patients with cardiac disease and an uncomplicated course should be encouraged to breast feed. 45Department of O&G, Sarawak General Hospital
  • 46. SAFETY PROFILE OF CARDIOVASCULAR DRUGS DURING LACTATION: Drug Recommendation Comments Digoxin Safe Amount ingested is far below the paediatric recommended dose Quinidine Safe Amount ingested is far below the paediatric recommended dose Procainamide Safe Amount ingested is far below the paediatric recommended dose Amiodarone Not Safe Excreted in significant amount in breast milk Verapamil Safe Amount ingested is far below the paediatric recommended dose Propanolol Safe No adverse effects seen Metoprolol Safe Amount ingested is far below the paediatric recommended dose Atenolol Safe No adverse effects seen ACE-I Not Safe 46Department of O&G, Sarawak General Hospital
  • 47. Anticoagulation in Pregnancy:Indications:1. Mechanical heart valves.2. Deep venous thrombosis & thromboembolism - the risk of DVT is 5 times greater in the pregnant state.3. AF associated with structural heart disease.4. Miscellaneous conditions eg. Peripartum Cardiomyopathy, Primary Pulmonary Hypertension, Eisenmengers Syndrome, Complex Congenital Heart Disease. AVAILABLE ANTICOAGULANTS: 1. Oral anticoagulants: 1.1 Warfarin during pregnancy is associated with warfarin embryopathy in 2 - 4% of newborn. 1.2 The likelihood of fetal complications appears to be significantly higher if the warfarin dose is more than 5 mg daily. 2. Unfractionated heparin 2.1 Heparin does not cross the placenta. 2.2 Use Activated Partial Thromboplastin Time (APTT) to monitor 2.3 Can be given subcutaneously or intravenously twice a day 2.4 Adjust dose to achieve APTT ratio of 1.5 - 2.5 2.5 Check APTT 4-6 hours after injection 2.6 Complications related to long term heparin use include abscesses, hematomas, thrombocytopenia and osteoporosis. 3. Low molecular weight heparin (LMWH) 3.1.1 While LMWH does not require APTT monitoring because of superior bioavailability and have fewer complications of thrombocytopenia or osteoporosis, the effectiveness in women with mechanical valves is questionable. 3.1.2 The use of LMWH in patients who are on life-long warfarin is controversial as the levels cannot be monitored. Subcutaneous heparin for the period of organogenesis (<13 weeks) and just prior to delivery should be used instead of LMWH. 47Department of O&G, Sarawak General Hospital
  • 48. Choice of anticoagulantsDuring pregnancy, there are 3 options for anticoagulation. The choice of which should bedecided in consultation with patient and her family.Option I: Combined heparin & oral anticoagulants First trimester: Unfractionated heparin / LMWH Second trimester till 36lh week: Warfarin From 36lh week: Unfractionated heparin / LMWHOption II: Full dose heparin throughout pregnancyOption III: Continuous Warfarin therapy First trimester till 36th week: Warfarin From 36th week: Unfractionated heparin / LMWHThere is no completely safe method of anticoagulation during pregnancy. In patients with highrisk of thromboembolism such as mechanical heart valves and mitral stenosis with atrialfibrillation, Option III is advocated. Should the patient choose to use heparin during firsttrimester, she should be made aware of the higher risk of valve thrombosis andthromboembolism.If planned for caesarean section at 38 weeks then change from warfarin toheparin from 37 weeks and revert back to warfarin 1 or 2 days after LSCS 48Department of O&G, Sarawak General Hospital
  • 49. 2.3.6 BRONCHIAL ASTHMA IN LABOUR_______________________________________________________________________________________Bronchial asthma is one of the most common severe pulmonary disorders complicatingpregnancy. The effect of pregnancy on the severity of asthma and the effect of asthma onpregnancy are uncertain. However it has been observed that patients with well-controlledpre-pregnancy asthma tend to tolerate pregnancy well. Pregnancy is associated withworsening of symptoms in one third of women.Antenatal Assessment:All patients with bronchial asthma should be booked for delivery in a hospital. A detailclinical history should elicit the following information:1. Frequency of attack2. Interval between attacks3. Type and regularity of medication4. Last attackPatient with chronic asthma should have:1. A review by physician in the combined clinic for assessment of: 1.1 The respiratory system (RR/Cyanosis/ PEF) 1.2 Response to drug treatment (to continue/ optimize medication)2. An obstetrics plan drawn by O&G specialist in the combined clinic.3. Serial ultrasound scans to assess fetal growth pattern (in order to detect IUGR). Management in Labour: 1. Reassess status of respiratory system 1.1 Refer to Physician x 1.2 The presence of bronchitis should be treated with antibiotics 1.3 The presence of bronchospasm should be treated with bronchodilators (use corticosteroids in the absence of adequate response). Intravenous hydrocortisone 2mg/kg body weight every 4 hours. 2. Labour monitor in the usual manner. 3. Continue anti asthmatic medication. 4. Patient should be well hydrated. 5. Patient should be well oxygenated 6. Pulse oxymeter. 7. Provide adequate analgesia. 8. Administer intravenous hydrocortisone (l00mg) if patient is or has been on corticosteroids. 49Department of O&G, Sarawak General Hospital
  • 50. 9. CTG monitoring of fetus. 10. In the event of postpartum hemorrhage, use oxytocin. 11. Use oxytocin for induction and augmentation of labour. 12. Avoid carboprostPost-partum:1. Encourage breast-feeding among asthmatic mother.2. Anti-asthmatic drugs are minimally excreted in breast milk and patient may continue medication while breast feeding. Acute asthmatic attack is an emergency and may require joint management with the physician and anaesthetist. 50Department of O&G, Sarawak General Hospital
  • 51. 2.3.7 DIABETIC MOTHER IN LABOUR_______________________________________________________________________________________INTRAPARTUM CAREDelivery should ideally be a planned event. A spontaneous vaginal delivery is generallyaimed for. The timing of the delivery depends on certain factors:  Uncomplicated, well controlled DM not requiring insulin therapy with normal fetal growth, plan for delivery between 38 to 40 weeks (Preferably deliver at 39 weeks)  GDM/IDDM requiring insulin therapy deliver at 38 weeks or earlier if IndicatedIf elective preterm delivery is contemplated, steroid therapy to enhance fetal lungmaturation has to be considered. Since this antagonizes insulin activity, it isrecommended to be done in the hospital with 2 hourly blood glucose determinations, indiabetic, patients with poorly controlled diabetes. Insulin infusion may be requiredMonitoring1. Biochemical monitoring is required when in established labour: Capillary glucose estimation - 2 hourly Random blood glucose - 4 hourly Serum electrolytes - 4 hourly Urine acetone - 4 hourly 2. Glucose levels should be maintained between 4-6 mmol/L to prevent neonatal hypoglycemia. Insulin therapy 1. Insulin infusion should be commenced when the capillary glucose level exceeds 7.0mmol/l. Insulin should be administered via a syringe pump. Solution 1. 20 units of soluble insulin / Actrapid (0.2ml of 100 units/ml solution) + 19.8 ml of normal saline in a 20 ml syringe. This gives a concentration of Insulin 1 unit/ml. 51Department of O&G, Sarawak General Hospital
  • 52. Insulin infusion requirement Insulin infusion requirement should be based on the sliding scale regime: Blood glucose (mmol/l) Rate of insulin via syringe pump 7.0-10.0 2 units/hour 10.1-15.0 3 units/hour 15.1-20.0 4 units/hour 1. All diabetic mothers in labour should have a maintenance drip Dextrose 5%, 1 pint every 4 hours. 2. Any electrolytes imbalance should be corrected accordingly based on serial monitoring of blood investigations.Elective Caesarean Section 1. She should be fasted from 12 midnight. 2. Antacid (oral ranitidine 150 mg) is given at 6.00 am on the day of operation. 3. Subcutaneous insulin is omitted. 4. Plasma glucose estimation is done at 6.00 am. Insulin infusion is required as per sliding scale. 5. 5% dextrose infusion is started at 6.00 am at a rate of 125 ml/hour. 6. 30 ml sodium citrate is given orally when called to the operating theatre. 7. Prophylactic antibiotic is given at induction of anaesthesia for both elective and emergency procedures. 8. Thromboprophylaxis in the form of subcutaneous unfractionated heparin or LMWH, thromboembolic deterrent (TED) stockings and early ambulation is recommended postoperatively for all caesarean sections for 7 days or till discharge from ward. 9. Patients at high risk of DVT/PE should be given LMWH for a total of 7 days even after they are dischargedPOSTPARTUM CAREGlucose monitoring Capillary glucose monitoring is required in the immediate postpartum period (initial 24 hours). • GDM requiring insulin therapy antenatally - 4 hourly • Pregestational diabetes meelitus - 4 hourly • GDM on diet modification alone - not required 52Department of O&G, Sarawak General Hospital
  • 53. All women with GDM/IGTT should have a glucose tolerance test performed at 6 weeks postpartum. Even if this is normal, they should be warned of the risk of developing abnormal glucose tolerance in the future (risk quoted as 36% after 24years). Insulin therapy In the postpartum period endogenous insulin activity should rapidly returns to normal.  GDM on insulin therapy antenatally - discontinue insulin  IDDM - resume pre-pregnant insulin regime  NIDDM - resume pre-pregnant oral hypoglycemic regimeBreast feeding 1. Breast feeding should be encouraged in all women. An additional 40-50 g carbohydrate is advised during lactation. 2. In breast feeding, those who require > 2.5 mg Glibenclamide or its equivalent before conception should remain on insulin. 3. Metformin may be passed into the breast milk in small amounts. While the manufacturer recommends that it is not used during breast feeding. If the mother is a type 2 diabetic on metformin then it is considered safe to continue while breast feeding. It is the recommendation from the 2008 NICE guideline.Contraception 1. To avoid unplanned pregnancies, it is important to practice contraception. 2. lUCDs are suitable in diabetic women and the same contraindications apply as for the general population 3. Combined Oral Contraceptive pills have only a slight effect on glucose tolerance and can be used. However in those who wish to permanently limit their family size, sterilization may be appropriate.Neonatal care 1. A pediatrician should be available at delivery 2. Neonatal hypoglycemia should be looked for especially if maternal glycemic control has not been ideal antenatally 3. Neonatal glucose concentration should be assessed - At birth - 2-4 hourly for 24-48 hours thereafter 4. Early feeding is ensured Indications for admission into the neonatal care unit I. Fetal macrosomia (birth weight > 4.0 kg) 2 Persistent neonatal hypoglycemia (< 2.6 mmol/1) 53Department of O&G, Sarawak General Hospital
  • 54. 2.3.8 RHESUS NEGATIVE MOTHER_______________________________________________________GENERAL CONSIDERATIONS:1. Advice antenatal follow up in hospital.2. Advise hospital delivery.3. Routine antenatal RhoGAM at 28 and 34 weeks in non-sensitized patient 4.1 Further Coomb‟s test is not indicated after antenatal RhoGAM 4.2 Specialist follow up is necessary for sensitized patient.4. Antenatal RhoGAM also indicated if: 5.1 antepartum hemorrhage 5.2 external cephalic version 5.3 trauma to abdomen 5.4 Invasive procedure such as amniocentesis or chorionic villous sampling5. Details of past medical/obstetric history: 5.1 history blood transfusions 5.2 history of induced/spontaneous abortion 5.3 history of RhoGAM injection during previous pregnancy 5.4 history of invasive procedures such as amniocentesis or CVS 5.5 history of threatened miscarriage >12 weeks 5.6 history of ectopic pregnancy 5.7 history of surgical intervention >12 weeks7. Husbands / Spouses blood groupINDUCTION OF LABOUR:Confirm 2 units of whole blood before starting induction of labour.LSCS:1. Confirm 2 units of whole blood.2. Intra-operative: 2.1 Pack pelvic gutters to reduce risk of feto-maternal transfusion 2.2 Deliver the placenta by CCT. Avoid manual removal of placenta.IN LABOUR: 1. Check antenatal history 2. Confirm 2 units of whole blood 3. Vaginal delivery if no contraindication 4. Fetal monitoring/augmentation of labour as in normal cases 5 At delivery, take cord blood for 5.1 Hemoglobin, ABO and Rhesus grouping 5.3 Coombs test 5.4 Serum bilirubin 5.5 G6PD status - as for all newborn babies 54Department of O&G, Sarawak General Hospital
  • 55. POSTPARTUM PERIOD1. RhoGAM to be given within 72 hours (the earlier the better) if baby is Rhesus positive and mother is Coombs negative2. KIV Kleihauer test to adjust dose of RhoGAM in case of: 2.1 LSCS 2.2 MRP3. Document if RhoGAM is given in the case records and patient home based card (PINK BOOK)4. Inform mother regarding the babys Rhesus status and document in mothers home based card (Pink Book)  Antenatal: Do Coombs test at monthly intervals  Do not give RhoGAM to a patient whos positive for antibodies  Any Rhesus negative woman who suffered miscarriage (even if only threatened miscarriage) warrant administration of RhoGAM to minimize risk of isoimmunisation. 55Department of O&G, Sarawak General Hospital
  • 56. 2.3.9 HIV IN PREGNANCY_______________________________________________________________________________________APPROACH1. Prenatal care.2. Access to HIV counseling and testing.3. Adherence to a recommended prevention strategy.4. Availability of antiretroviral medications.5. Availability of trained healthcare staff to counsel, prescribe and administer Zidovudine (ZDV) during pregnancy and labour.ANTEPARTUM:Screening"Test unless refused" or "routine screening with the option to opt out" policyCounseling of pregnant women with HIV:1. Personal prognosis based on lymphocyte subset and viral load, if available.2. Illicit drug use (where relevant).3. Counseling and HIV testing for the spouse / partner.4 . Risk of Mother-to-child-transmission (MCTC).5 . Neonatal prognosis, natural history of HIV in children.6. Benefits of ZDV therapy for mother and baby - reduction in MTCT.7. Possible ZDV side-effects to mother and baby.8. No method of prenatal diagnosis as MCTC risk is highest during intrapartum.9. Breast feeding is contraindicated as the substitute formula feed is available. Notification Notification of case to health department using designated form, if it is not already been done by the referring health clinic.GOALS OF ANTIRETROVIRAL THERAPY FOR THE BABY OF INFECTEDWOMEN:1. To preserve the current and future health of the mother.2. To prevent perinatal transmission / MTCT.3. To ensure the health of the fetus and neonate.ANTI RETROVIRAL THERAPY: ACTG 076 PROTOCOLAntepartum 1. T. ZDV 2COmg TDS starting after 14 weeks gestation till delivery. 56Department of O&G, Sarawak General Hospital
  • 57. Intrapartum 1. IV ZDV 2mg/kg in first hour 2. 1 mg/kg/hr until delivery (clamping of cord)If IV ZDV not available: 1. T. ZDV 300 mg Q3H until delivery. Induction of Labour 1. Begin ZDV at the time of inductionElective Caesarean Section 1. Begin ZDV 4 hours before surgeryPostpartum a) Mother to continue T. ZDV 200mg TDS for 6 weeks. b) Baby to be started on Syrup. ZDV 2mg/kg Q6H within 12 hours of life, for a total of 6weeks. c) Baby should be attended by pediatrics team for further assessment.  For HIV-infected woman who in already on therapy becomes pregnant, the risks and benefits of continuing antiretroviral treatment need to be discussed.  If the pregnancy is detected during the first trimester, the woman needs to be counseled regarding the limited data on the safety of the drugs on the fetus and newborn.  If discontinuation of treatment is considered, all drugs should be stopped simultaneously and restarted after the second trimester.  If the current drug regimen does not contain ZDV, this needs to be incorporated into the drug regimen in line with the ACTG 076 protocol at the second trimester.Highly Active Antiretroviral Therapy (HAART)Consult Physician regarding commencement on HAART.1. For selected cases, HAART should be considered for: 1.1 AIDS by CDC definition 1993 1.2 High viral load/CD4 cell count <350 cells/mm3 1.3 Patients with potentially good compliance with the HAART.2. HAART may be complicated by the following issues: 2.1 More side effects; 2.2 Adherence to therapy; 2.3 Development of resistance which will restrict future options of therapy. 57Department of O&G, Sarawak General Hospital
  • 58. ANTEPARTUM:Clinical examinationTo look for HIV / AIDS related complex: 1. Skin: dermatitis, folliculitis, Kaposi sarcoma. 2. Chest infection. 3. Hepato-splenomegaly. 4. Haematologically 5. Genital lesion and infection: herpes simplex, carcinoma of cervix.Laboratory monitoring 1. Full blood counts 2. Liver function test 3. Renal profile 4. ESR 5. Creatine kinase (if on ZDV) 6. Toxoplasma serology 7. STD screening eg. VDRL/TPHA, Hepatitis B, Hepatitis C (including for spouse / partner) 8. CD4 measurements: 3-6 monthly 9. Viral load (if available) 10. OGTT Follow up 1. Clinical assessment of side-effects eg. anaemia, nausea, vomiting, myalgia, headaches, etc. 2. FBC2-weekly 3. CD4 measurements 3-monthly 4. Check drug compliancePrenatal Care 1. Combined care with the involvement of Physician and Pediatrician. 2. Frequency of antenatal follow up should be as for high risk pregnancies. 3. Avoid any invasive procedures such as CVS & amniocentesis. 4. Serial ultrasounds for fetal growth monitoring.INTRAPARTUM:1. Minimize the number of medical personnel handling the case2. Universal precaution, disposable laundry and equipment, double gloving, elbow- length latex gloves, goggles (when performing vaginal deliveries or MRP), Plastic apron should also be worn beneath the sterile surgical gown.3. Use blunt needles eg. blunt taper point and tissue-handling forceps.4. ZDV regimen as stated earlier. 58Department of O&G, Sarawak General Hospital
  • 59. 5. Blood spillage should be dealt with as soon as possible. Refer to Standard Precaution published by AIDS / STI Section, MOH for details. 5.1 Freshly prepared Sodium Hypochlorite (Chlorox) 1:10 or sprinkle chloride granules to cover the spillage and left for 5-10 minutes. If it is a large spillage, it may be covered with suitable absorbent material. 5.2 The spillage should be wiped up using paper towels or suitable absorbent material. Avoid direct contact between gloved hands and the spillage. 5.3 The area should be mopped with Sodium Hypochlorite (Cholorox) 1:100. 5.4 For a large spill, a mop can be used to wipe instead, but the mop needs to be disinfected with Sodium Hypochlorite and rinsed thoroughly. 5.5 Equipment used for management of spillage should be decontaminated.6. Placenta to be handled as below before disposal. Refer to Standard Precaution published by AIDS / STI Section, MOH for details. 6.1 For health care workers: 6.1.1 Wear plastic apron and double gloves when examining placenta. 6.1.2 Avoid splashes. 6.2 For Muslims: 6.2.1 Immerse placenta in Sodium Hypochlorite 1:10 for 10 minutes. 6.2.2 Drain out and carefully seal in double plastic bags before handing over to relatives. 6.2.3 Provide relatives with 2 pairs of disposable latex / rubber gloves. 6.2.4 Educate them on safe handling of the placenta at home. 6.2.5 If the Muslim relatives do not wish to take the placenta home, discard as clinical wastes. 6.3 For Non-Muslims: 6.3.1 Discard as clinical wastes.Mode of delivery: 1. Caesarean section should be offered at 38 weeks for woman in the following situations: 1.1 Women who have not received antiretroviral mono-therapy. Such therapy should be commenced as soon as HIV is recognized. 1.2 Women receiving antiretroviral mono-therapy (instead of combined antiretroviral agent regimens) regardless of the viral load. 1.3 Women receiving less than 4 months of HAART. 1.4 Patients with detectable viral load regardless of the received therapy.Recommended viral load threshold is <50 RNA copies/ml. 1.5 Women in whom the viral load determination is not available or has not been done. 1.6 Women with unknown prenatal care. 2. If patient refuses Caesarean section, the following should be observed: 2.1 Avoid invasive procedures such as scalp electrodes and fetal 59Department of O&G, Sarawak General Hospital
  • 60. scalp sampling. 2.2 Selective episiotomy and not routine. 2.3 ARM should be undertaken only if labour progress is adequate. 2.4 If assisted delivery is required, forceps may be preferable to vacuumextraction given the risk of micro-lacerations of the scalp from the vacuum cup. 2.5 Cord should be clamped early. 2.6 Prophylactic antibiotics should be instituted especially in operative delivery.POSTPARTUM:1. Both mother and baby are to continue with oral ZDV for 6 weeks.2. Baby to be seen and followed up by Paediatrician for further assessment.3. Mother to be followed up by the Medical team.4. Breastfeeding is contraindicated. FOLLOW UP: 1. Permanent sterilization (bilateral tubal ligation) should be offered or considered. 2. Barrier contraceptive methods should be advised including the use of spermicide this should continue to be practiced even after a bilateral tubal ligation, to prevent transfer of virus from one partner to another. 3. Annual Pap smear. 4. Couple to be followed up by the Medical team. 60Department of O&G, Sarawak General Hospital
  • 61. 2.3.10 BREECH/ECV_______________________________________________________________________________________Breech presentation is encountered in 3 - 4% of term deliveries. The frequency ofencountering an undiagnosed breech has reduced since the increased use of ultrasound .Management optionsBreech at term:1. Confirm presentation2. Confirm gestation3. Gross fetal anomalies eg. hydrocephalus4. Placenta praevia5. Pelvic tumours e.g. cervical fibroidOption one: Offer external cephalic version (ECV)1. ECV: Trans-abdominal manipulation of a breech-presenting fetus into a cephalic presentation2. Safe procedure when patient is carefully selected.3. Timing: Done at 37 weeks gestation to reduce the risk of spontaneous version and reduce risk of prematurity if the need arises to deliver baby in the event of fetal distress (while attempting ECV).4. Rule out contraindications: 4.1 Independent indication requiring LSCS (eg. Placenta praevia) 4.2 Independent indication for vaginal delivery (eg. IUD) 43 In labour 4.4 PROM 4.5 Oligohydramnios 4.6 Uterine scar 4.7 IUGR 4.8 Fetal abnormality 4.9 Uterine abnormality/ pathology 4.10 Hypertensive disorders or other medical disorders 4.11 Non-reactive CTG 5. Preparation and procedure: 5.1 IV line, Consent 5.2 Ultrasound: to document presentation prior to procedure 5.3 Empty bladder 5.4 Baseline CTG 5.5 Intravenous infusion of tocolytic for 30 min prior to procedure (routinely of selectively are both acceptable practice) 5.6 Perform ECV 5.7 Post procedure CTG for 40 min 5.8 IM RhoGAM in non-sensitized Rhesus negative patient 61Department of O&G, Sarawak General Hospital
  • 62. EXTERNAL CEPHALIC VERSION (ECV)1. Place patient in a supine position.2. Talc is sprinkled over the maternal abdomen.3. The initial step is to displace the breech / from the pelvic brim.4. With a pelvic grip, the breech is displaced to one iliac fossa; towards the side of the fetal back (forward somersault).5. The other hand is placed, over fetal head and is pushed towards the patients flank and then towards her pelvis.6. Both hands work in unison to keep the fetus in a flexed position.7. The version force is applied to both the fetal poles.8. The pressure should be gentle and intermittent while the pressure is applied, the fetus as a whole should be gently rocked from side to side of the mothers abdomen.If ECV is successful: Rest of the pregnancy to be managed as in a normal patient. If ECV isunsuccessful: Proceed to option twoOPTION 2: Elective Caesarean Section1. Independent indications requiring LSCS.2. When patient is not suitable for option one.3. When patient requests for a caesarean section.4. Hyperextended neck.5. IUGR.6. Bad obstetric history.7. Subfertility.8. Preterm breech with estimated birth weight less than 2500gm.Option two is being opted for more frequently after the publication of TermBreech Trial.OPTION 3: Vaginal breech delivery1. Currently SGH guidelines states that this option is only reserved for those who strongly refused both ECV and LSCS after intense counseling by a specialist.2. In certain circumstances, vaginal breech delivery may be a better and safer option than an emergency caesarean section: 2.1 Impending delivery of breech (os full and the breech can be seen at the introitus) 2.2 Os if full or almost full and the presenting part is well descended in the vagina before the patient is given regional anaesthesia. 2.3 There is no OT available and delivery is expected at anytime 2.4 IUD 62Department of O&G, Sarawak General Hospital
  • 63. 3. Rule out contraindications : 3.1 Independent indication requiring LSCS (eg. Placenta praevia, pelvic mass) 3.2 Flexed / footling breech 3.3 Hyperextended head 3.4 Estimated fetal weight < 2500gm 3.5 Estimated fetal weight > 3500gm 3.6 Previous uterine scar 3.7 Fetal abnormality which may cause dystocia 3.8 Fetal compromise 3.9 IUGR 4. Confirm favourable features: 4.1 Extended breech 4.2 Suitable attitude 4.3 Estimated fetal weight between 2500gm to 3500gm 4.4 Adequate bony pelvis 4.5 Spontaneous onset labour 4.6 Non primigravida 5. Patient husband should be informed of risks to both mother and fetus in vaginal breech delivery. 6. When in active labour; 6.1 Progress of labour should be similar to cephalic presentation. 6.2 Augmentation should consult specialist 6.3 CTG tracing should be continuous 7. Rule out cord prolapsed when membranes rupture. The most reliable method of delivery of the after coming head is by forceps. This allows maintenance of the flexion of the fetal head and controlling the delivery of the head. In addition, the force of pull is applied over the head and NOT the spine.Role of ultrasound in the management of a fetus in breech presentation1. Confirm gestation2. Rule out multiple pregnancy3. Type of breech4. Attitude5. Estimated fetal weight6. Amniotic fluid index7. Placenta site8. Uterine anomaly9. Uterine / pelvic pathology 63Department of O&G, Sarawak General Hospital
  • 64. 3.3.11 TWINS IN LABOUR______________________________________________________ Twin pregnancy is a high risk pregnancy Maternal risks Fetal risks Anaemia IUGR Preterm delivery Congenital anomalies Hypertension TTTS APH Polyhydramnios Polyhydramnios Cord accident Increase operative delivery Increase operative delivery PPH Antenatal 1. 1st trimester scan to determine chorionicity (separating membranes does not determine chorionicity) 2. Book/Follow-up in hospital 3. Advise on the important of hospital delivery 4. Serial growth scan, interval depend on chorionicity (2 weekly for MCDA & 4 weekly for DCDA) 5. Timing of delivery 5.1 Uncomplicated 5.2 DCDA : 37-38/52 5.3 MCDA: 36-37/52 5.4 MCMA: After 32-34 weeks (After discussion with pediatrics team, corticosteroid cover and availability of the ventilator). 6. If complicated assess case by case basis after careful review by specialist/consultantMode of delivery:Caesarean section is recommended in: 1. Non-cephalic first twin 2. Patient with previous LSCS 3. MCMA TwinCaesarean section also may be considered in the following circumstances: 1. Death of one fetus especially the leading twin 2. MCDA twin 3. Any other complicated twin pregnancy. 64Department of O&G, Sarawak General Hospital
  • 65. When vaginal delivery is planned: 1. Continuous fetal monitoring of both fetuses. 2. Provide adequate pain relief (preferably epidural). 3. GSH/GXM 2 units of blood 4. Counsel patient regarding second stage.Second stage of labour: 1. Medical staff in attendance: 1.1 Two O&G doctors 1.2 Two pediatrics doctors 1.3 Two nursing staff 2. Standby operating theatre. 3. Episiotomy. 4. Delivery of first twin as a singleton.After delivery of the first twin: 1. Determine lie of second twin (preferably with ultrasound scan). 2. If non-longitudinal lie: Turn fetus to longitudinal lie by ECV (Preferable) or Internal podalic version. 3. Monitor uterine contractions. 4. Consider starting oxytocin drip if uterine contractions are weak (Increment every 5 minutes). 5. If membranes intact - allow spontaneous rupture/ARM. 6. Deliver fetus. 7. Following placenta delivery to start on 40 units of oxytocin infusion drip. 8. Placenta to be inspected for chorionicity and document in case notes. 65Department of O&G, Sarawak General Hospital
  • 66. 3.3.12 TRIAL OF SCAR______________________________________________________A patient with a previous uterine scar (Caesarean section, myomectomy) may be allowedto deliver vaginally following a risk assessment. The patient must be counseled regardingthe associated risk of such an attempt and a management plan outlined in the antenatalperiod. Trial of Scar should only be carried out in hospitals with O&G specialistsAntenatal Assessment 1) Book for hospital delivery. 2) Obtain information regarding previous surgery - review the operation notes, communication with previous obstetrician / hospital; to exclude any contraindications for trial of scar. 3) Ultrasound assessment of fetus especially placenta localization at or beyond 30 weeks gestation 4) Risk assessment. 5) Consider informed choice 6) Assessment by specialist by 36-37 weeks gestation.Risk assessment should determine the following: 1) Factors regarding previous surgery. 2) Indication for the previous Caesarean section/ uterine surgery. 3) Type uterine incision. 4) Intra-operative findings/ difficulty. 5) Significant events in postoperative period (secondary PPH/ febrile episodes/ wound breakdown). Factors associated with current pregnancy 1) Presentation. 2) Lie of fetus. 3) Number of fetus. 4) Placental site 5) Pregnancy interval <18 months 66Department of O&G, Sarawak General Hospital
  • 67. Management1. Trial of labour in selected cases based on risk assessment, for 6 to 8 hours.2. When patient is admitted in labour: 2.1 Review by medical officer / specialist; 2.2 Set IV cannula; 2.3 Full blood count; 2.4 GSH/GXM 2 (two) units of whole blood; 2.5 Continuous CTG monitoring 2.6 Partogram. Monitor for slow progress - evaluate causes for disproportion; 2.7 Monitor for signs of impending uterine rupture: 2.7.1. Abnormal CTG 2.7.2. Rapid maternal pulse > 100/min; 2.7.3. Persistent suprapubic tenderness and pain; 2.7.4. Persistent abdominal pain, especially if present in between contractions; 2.7.5. Haematuria.Induction of labour (IOL) in women with previous single scar1. IOL with prostaglandins may increase the risk of uterine rupture by 2.4x2. The use of prostaglandins is still acceptable but requires specialist approval3. Selection of cases to be decided only by specialist/Consultant.4. Usual precautions/ monitoring to accompany the use of prostaglandins.5. In Sarawak General Hospital only 1 prostin 1.5mg insertion is allowed6. Mechanical methods - Foley‟s catheter or Cervical Ripening Balloon (CRB)Augmentation of labour with oxytocin1. Case selection to be decided by specialist.2. Use infusion pump to regulate oxytocin is preferable.3. Usual precaution/ monitoring to accompany the use of oxytocin. Use of Epidural analgesia No contraindication Manual exploration of the uterus 1. No benefit to perform routine manual exploration following the delivery of placenta. 2. Internal palpation of the lower segment should be reserved for patients with abnormal bleeding. Elective LSCS at 38 weeks Gestation 1. Independent in current pregnancy (eg. placenta praevia, malpresentation) 2. Previous LSCS for recurrent causes (eg. Contracted pelvis) 3. Previous vertical scar (classical scar) 4. Breech or twin pregnancy 5. Mothers who refuse a „trial of scar‟ despite being counseled appropriately 6. Past history of myomectomy where uterine cavity was entered. 67Department of O&G, Sarawak General Hospital
  • 68. 1.3.13 INTRAUTERINE DEATH_________________________________________________________ Independent confirmation by 2 persons before informing patient!Ultrasound features in intrauterine death1. Absent fetal heart activity2. Non-pulsatile aorta3. Spalding sign - irregular overlapping of skull bones4. Roberts sign - appearance of gas shadow in heart chambers and great vessels5. Absence of fetal movementLabour management1. Mode of delivery - aim for vaginal delivery.2. DIVC screening prior to induction of labour.3. Induction of labour as for viable pregnancy (refer to chapter on IOL).4. Investigation to determine cause5. 3rd stage-Watch for PPH.6. KIV prophylactic antibiotic e.g. maternal pyrexia7. Record fetal appearance - note abnormalities by medical officer or registrar.8. Offer patient the option of isolation room after delivery.9. To provide bereavement counseling prior to discharge.10. Give appointment date at the postnatal clinic to review results and progress of patients (preferable to be seen by the doctor who has managed the patient during antenatal/ Intra-partum period).11. Suppression of lactation with cabergoline, 1mg on first day after delivery.Caesarean section for IUD1. Decision to be made by a specialist.2. Patient needs to be counseled regarding the decision.3. Indications: 3.1 Cephalo - pelvic disproportion 3.2 Abnormal lie 3.3 Placenta praevia 3.4 Two previous LSCS 3.5 Previous classical caesarean section 3.6 Fetal anomaly (which may cause dystocia) 68Department of O&G, Sarawak General Hospital
  • 69. Establishing the cause of fetal death1. Document the events related to an IUD.2. Investigate to determine the cause of death.3. Offer a postmortem examination of fetus 3.1 As this a sensitive issue in our community, counseling about postmortem is only to be given by registrar/specialist/consultant 3.2 Document if postmortem is declined4. Photograph all fetuses with dysmorphism.5. Mandatory "babygram" only in the presence of structural / skeletal deformities.6. Karyotype when indicated.7. Placental swab for C&S / placental tissue for histopathological examination. Minimal placental tissue for HPE includes 1/8 of placenta (full thickness) from the center till the margin. Both maternal and fetal surfaces as well as membrane must be included. Site of cord insertion is not necessary, but a minimum 2cm long umbilical cord, 5cm away from the site of insertion should be obtained along for HPE. In cases of PPROM / PROM, section of the membranes at the site of rupture should be taken for HPE.8. Bereavement counseling is a major component of management.9. Maternal investigations: 9.1 FBC 9.2 Blood/Rhesus group 9.3VDRL 9.4 TORCH 9.5 Lupus anticoagulant and anti-cardiolipin (6/52 after delivery) 9.6 MOGTT at the time of IUD 9.7 In hydropic baby 9.7.1 Send maternal blood for Hb electrophoresis and DNA study for alfa- thalassemia if the maternal MCV is low. 9.7.2 If maternal MCV is low, screen also the partner 9.7.3 Kleiheur- test 9.7.4 Indirect Coomb‟s test 69Department of O&G, Sarawak General Hospital
  • 70. 2.4 MANAGEMENT OF LABOUR2.4.1 Induction of labour2.4.2 Augmentation of labour2.4.3 Management of the first stage of labour2.4.4 Management of the second stage of labour2.4.5 Fetal monitoring in labour2.4.6 Pain relief in labour 70Department of O&G, Sarawak General Hospital
  • 71. 2.4.1 INDUCTION OF LABOUR (IOL) _____________________________________________________ Prerequisites: 1. Gestation period checked and confirmed by registrar / specialist. 2. Reactive CTG. 3. Group and Cross Match 2 units of blood (GSH). 4. Absence of contraindications. Indications for IOL: Decision for induction must be on individual basis INDICATION PERIOD OF GESTATION Post dates 40 weeks and 7 days GDM on diet control 38 -40 weeks (preferably deliver at 39 weeks) GDM / DM requiring insulin 38 weeks, or earlier PIH on medication 38 to 40 weeks. NOT later than 40 weeks. Pre-eclampsia 37 weeks or earlier if indicated Eclampsia Immediate delivery after stabilization Intrautrine growth restriction Depending on condition and POA Reduced fetal movement Beyond 38 weeks (after discussion with specialist and patient counseling) Twins Refer to twin management Bad obstetric history 38 weeks or earlier (after discussion with specialist) Intrauterine death To discuss with specialist and also depend patient wish. CERVICAL SCORING SYSTEMS BISHOPS SCORE Cervical feature Pelvic score 0 1 2 3 Dilatation (cm) 0 1-2 3-4 5-6 Effacement (%) 0-30 40-60 60-70 80+ 0-30 (cm) Station -3 -2 -1/ 0 + 1/+2 Consistency Firm Medium Soft Position Posterior Mid-position Anterior 71 Department of O&G, Sarawak General Hospital
  • 72. MODIFIED BISHOPS SCORE (CALDER SCORE)Cervical feature Pelvic score 0 1 2 3Dilatation (cm) <1 1-2 2-4 >4 !Length of cervix (cm) >4 2-4 1-2 <1Station (cm) -3 -2 -1/0 +1/+2Consistency Firm Average Soft .Position Posterior Mid; Anterior - - The cervical score is used to assist in making a decision regarding induction of labour. Favourable cervix: > 7 (IOL by ARM ± augmentation of labour) Unfavourable cervix: < 7 (Induction with vaginal Prostaglandin) Documentation: The following information must be recorded when a decision is made for IOL 1. Indication 2. Timing of IOL 3. Mode of IOL: 3 1 Amniotomy 3.2 Vaginal Dinoprostone ( Prostin ) 3.3 Vaginal Gemeprost ( Cervegem ) 3.4 Others ( state ) 4. Decision by: IOL with prostaglandin: When induction of labour is undertaken with prostaglandins in an unfavourable cervix 1. Planned induction should be started early with prostin inserted at 7 am 2. Pre-existing short acting insulin dosage should be continued 3. Snacks are allowed 4. Capillary glucose estimation should be done 4 hourly until labour is established IOL with oxytocin: 1. Planned Induction should be started as early as possible in labour ward 2. Subcutaneous insulin is withheld 3. An intravenous infusion of 5% dextrose is commenced at a rate of 125 ml/hour 4. biochemical monitoring include: 4.1 capillary glucose estimation - 2 hourly 4.2 serum electrolytes, blood glucose & urine ketone - 4 hourly 72Department of O&G, Sarawak General Hospital
  • 73. 5. Insulin therapy: as per sliding scale for diabetic mother in labour 5.1 Patients on pre-existing insulin therapy, the insulin infusion are started at a rate of 1unit/hour. 5.2 For patients on diet modification, insulin infusion is only started when the capillary glucose level exceeds 7 mmol/l. 5.3 Insulin infusion requirement should be based on capillary glucose estimation. 6. Adequate analgesia is important. (Epidural analgesia would be ideal) 7. Continuous fetal heart rate monitoring is required 8. Normal progress of labour is anticipated. 9. Labour should not be prolonged. 10. A partogram must be started. 11. Should any additional intravenous fluids be necessary during labour such as oxytocin infusion or for rehydration, isotonic saline or Hartmanns solution should be used. Choice of Prostaglandin:Uterine height/Parity ProstaglandinUterine height < 22 weeks Gameprost ( cervagem) 1 mg 3-4 hourly, maximum 5 doses/dayUterine height > 22 weeks Dinoprotone (prostin), 3 mg , 6 hourly, maximum 2Nulliparous doses/dayUterine height > 22 weeks Dinoprostone (prostin) 1.5 mg, 6 hourly, maximum 2Para1-4 without scar doses/dayUterine height> 22 weeks Dinoprostone (prostin) 1.5 mg, need permissionOne previous scar from specialist if need more than 1 prostinUterine height > 22 weeks To discuss with specialist before embarking on IOLgrandmultipara with prostaglandin or oxytocin Suggested induction regime using Dinoprostone PGE2 (Prostin E2) is as follows: Day 1: maximum 2 prostin in a day, 6 hours apart. If cervix remains unfavourable, to rest for the night and continue coming morning. IOL should be started in the morning and should not be inserted beyond 5 pm. Day 2: To insert 3rd prostin in the morning. If cervix is still unfavourable after 3 prostins, discuss with specialist regarding the further management plan. Day 3: 4th prostin to be inserted if decided by specialist. Patient view also needs considered when the 4th prostin is required. Keep patient NBM at the time of insertion in anticipation of Emergency LSCS for failed induction. 73Department of O&G, Sarawak General Hospital
  • 74.  In summary, a maximum of 4 prostins would be used over a span of 3 days for low risk cases. High risk cases would be managed accordingly.  If uterine hyperstimulation is suspected, to administer IV/SC with Salbutamol (Ventolin) or Terbutaline (Bricanyl) STAT to reduce the intensity and frequency of contraction. A CTG must be performed to rule out any fetal distress. In district hospitals without O&G specialist, a maximum of 2 prostin can be inserted. If a third prostin is required then approval from an O&G specialist is required. MATERNAL AND FETAL MONITORING 1. CTG before initiation of induction of labour (Pre-induction CTG ) 2. Monitor uterine contraction, maternal pulse rate and fetal heart rate in the first 2 hours at 15 min intervals. 3. Repeat CTG in the first hour of initiation of induction of labour (Post induction CTG) 74Department of O&G, Sarawak General Hospital
  • 75. 2.4.2 AUGMENTATION OF LABOUR_______________________________________________________________________________________Consider augmentation in:1. Poor progress due to inadequate uterine contraction2. Absence of contraindications.3. Contraindications: 3.1 Fetal compromise 3.2 Malpresentation e.g. breech 3.3 Membranes intact, unless instructed by specialistAim:To achieve adequate contraction (3-5 contraction per 10 minutes; each lasting up to 35 to45secs).Decision by:1. Decision by registrar in normal risk cases2. Decision by specialist in high risk casesRegime:Refer to Oxytocin augmentation / induction regimeDocumentation on Partogram:1. Commencement of augmentation2. Effect upon contraction3. The increase of dosage against timeAugmentation to be stopped immediately when:1. Uterine hyperstimulation (more than 5 contractions in 10 minutes )2. Fetal distress3. Maternal hypotension / tachycardia ( Signs of uterine rupture ) LABEL DRIP BOTTLE CLEARLY STATING STRENGTH OF OXYTOCIN USED CAUTION: OXYTOCIN SHOULD NOT BE USED SOONER THAN 6 HOURS AFTER USE OF VAGINAL DINOPROSTONE (PROSTIN). 75Department of O&G, Sarawak General Hospital
  • 76. OXYTOCIN AUGMENTATION / INDUCTION REGIMEAim : To achieve good contraction, ie. 4 contractions in 10 minutes, with duration of contractions lasting up to 45 seconds.Dilution : 10 units (1ml) Oxytocin + 500ml Normal SalinePreparation : 1 ampoule = 10 units /1mlRegime : 1. To use either infusion syringe pump or IV drip infusion pump 2. Start at 2miu/min. 3. Increase every 30 minutes. 4. Maximum 32miu/min (32dpm or 96ml/hr). [20miu/min= recommended maximum dose by manufacturer] 5. 12 miu/min usually establishes adequate contractions.For high risk patients such as grandmultipara, one previous scar, heart disease inpregnancy, usage of a lower dose regime ie. (INCREMENTAL REGIME) is acceptable. Thedose is titrated upwards in a slower and smaller incremental increase. The maximumdose of oxytocin is also lower.* Note: 1 ml = 20 drops, 1 dpm = 3 ml/hr DOUBLING REGIME: DOSE DROPMAT INFUSION SYRINGE PUMP 2 miu/min 2 dpm 6 ml/hr 4 miu/min 4 dpm 12 ml/hr 8 miu/min 8 dpm 24 ml/hr 16miu/min 16 dpm 48 ml/hr 32miu/min 32 dpm 96 ml/hr INCREMENTAL REGIME: DOSE DROPMAT INFUSION SYRINGE PUMP 2 miu/min 2 dpm 6 ml/hr 4 miu/min 4 dpm 12 ml/hr 6 miu/min 6 dpm 18 ml/hr 8 miu/min 8 dpm 24 ml/hr 10 miu/min 10 dpm 30 ml/hr I2miu/min 12 dpm 36 ml/hr 76Department of O&G, Sarawak General Hospital
  • 77. 2.4.3 MANAGEMENT OF THE FIRST STAGE OF LABOUR_______________________________________________________________________________________1. Record the date and time of admission.2. Do a complete examination of patient following admission.3. Commence patient on a partogram to monitor progress of labour, once she is in active labour (>/= 4 cm, or earlier whenever necessary such as an IOL cases.4. Ensure accurate and complete recording of information in the partogram.5. Fetal monitoring : 5.1 Normal / low risk patients : Intermittent auscultation, intermittent CTG 5.2 High risk patients : Electronic fetal monitoring ( CTG ) - continuous6. Ensure patient passes urine / Bladder is catheterized when bladder is palpable.7. Urine to be tested for ketone, protein and sugar.8. Ensure the patient is adequately hydrated.Intermittent auscultation (where CTG is not available): 1. Listen to the fetal heart with a fetal stethoscope or hand held Doppler ultrasound monitor. 2. First stage: Performed for 1 min every 15 min between contractions. 3. Second stage: More frequently than during first stage (as required).Set up intravenous cannula in the following patients:1. Grand multipara.2. Multiple pregnancy.3. Previous LSCS.4. Breech presentation.5. Intrauterine fetal death.6. Patient having higher risk factors for operative delivery.7. Patient who is at risk of PPH.Intravenous maintenance fluid: (monitor input / output of fluid)1. P1H / PET (Do not overload).2. Diabetic (on DIK regime).3. Requiring augmentation of labour.4. Planned for epidural pain relief (ensure adequate hydration). Augmentation of labour: 1. Decision by registrar in normal or moderate risk cases. 2. Decision by specialist in high risk cases. 77Department of O&G, Sarawak General Hospital
  • 78. Group and save blood (GSH ):1. IOL2. Previous LSCS3. Breech4. Bad obstetrics history5. PIH/PET6. Diabetic7. IUD8. History of retained placenta9. Grand multipara10. History of PPH Continuous bladder catheterization: 1. Severe PET / Impending eclampsia / Eclampsia 2. Abruptio placenta 3. Cases that require close monitoring of urine output / renal function Accompanying person: 1. Encourage a relative to be with the patient (with the nurse monitoring labour). This is providing if the labour room is equipped and conducive to be husband friendly. Findings suggestive of satisfactory progress: 1. Regular, good contractions. 2 Progressively increasing in frequency and duration. 3. Rate of cervical dilatation, at least 1 cm per hour during active phase. 4. Presenting part remains well applied to cervix. Hyperstimulation: 1. Prolonged contractions (> 2 mins) 2. Frequent contractions (<1:2) 3. Tetanic contractions (continuous) 78Department of O&G, Sarawak General Hospital
  • 79. 3.4.4 MANAGEMENT OF THE SECOND STAGE OF LABOUR_______________________________________________________________________________________1. House officer must review and document on case note: 1.1 Time of Os at full dilatation. 1.2 Time of delivery of baby. 1.3 Time of delivery of placenta.2. Duration of 2nd stage depends on antenatal history (eg. cardiac disease) and parity.3. Generally allow : 3.1 One hour for primigravida 3.2 Half an hour for multiparous woman. 3.3 Patients on epidural analgesia can be allowed up to 3 hours, providing there is no maternal or fetal distress. The descent of the presenting part is delayed in patients on epidural.4. Remember to use information from the partogram to assist in decision to expedite delivery.5. CTG monitoring during the second stage of labour can be difficult to interpret due to loss of contact, even more so when the mother is bearing down. In high risk cases where monitoring is required, it may be necessary to use internal CTG electrodes.6. Ensure all CTG traces are interpreted, signed and dated. Time must be correctly stated.7. High risk patients should have IV access.8. Check that suction apparatus is functioning while preparing to conduct delivery.9. Appropriate gowning is necessary to conduct delivery.10. Clean and drape patient prior to delivery.11. Use local anaesthesia if episiotomy is required.12. Intramuscular Syntometrine / Syntocinon when anterior shoulder of fetus is delivered.13. Paediatric doctor should be on standby for high risk cases and instrumental deliveries.14. Practice active management of 3rd stage of labour (prophylactic oxytocics administration, controlled cord traction with or without early cord clamping).15. Be familiar with all equipment and availability / location of drugs in the labour room. 79Department of O&G, Sarawak General Hospital
  • 80. 3.4.5 FETAL MONITORING IN LABOUR______________________________________________________________________________________MODALITIES OF MONITORING IN SGH: 1. Intermittent auscultation 2. Electronic fetal heart monitor (daptone) 3. Cardiotocograph (CTG): a. External b. Internal 4. Fetal scalp blood pH testingMONITORING IN LABOUR WARD:On admission to labour ward: 1. All antenatal patients will have a baseline CTG trace for at least 20 minutes A. FOR LOW RISK CASES: 1. Intermittent fetal auscultation or using fetal daptone (approximately at 30 minute interval) 2. Record fetal heart rate on the partogram 3. Intermittent 20 minute CTG trace (2 – 4 hourly) 4. Record patient‟s name, NRIC, interpretation, the name of the doctor who reviewed and state the time on every CTG trace. 5. Continuous CTG monitoring is absolutely unnecessary B. FOR MODERATE RISK CASES: 1. Intermittent fetal heart monitoring with daptone (between CTG monitoring) 2. Intermittent 20 minute CTG trace with frequency to be decided by the registrar or specialist on duty. 3. Frequency and length of CTG trace dependent on individual case and the interpretation of the previous trace 4. All fetal heart recording have to be documented as above C. FOR HIGH RISK CASES: 1. Intermittent CTG tracing with the frequency to be decided by the registrar or specialist on duty 2. The CTG can also be left to continuously monitor the fetal heart rate but only need to print traces on intermittent basis if needed 80Department of O&G, Sarawak General Hospital
  • 81. 3. Continuous CTG tracing in exceptional cases may be needed where there are some abnormalities on the earlier traceREVIEWING CTG TRACE: 1. Normal CTG trace to be reviewed by a doctor or the attending midwife and tracing endorsed with date, time and name of doctor. 2. Report on tracing by HO / MO / Doctors. Comment on all components of the CTG. 3. Abnormal CTG trace have to be reviewed and endorsed by the medical officer or the specialist on dutyABNORMAL CTG TRACE: 1. Medical officer/ registrar or specialist on duty be informed immediately 2. The informed medical officer or specialist have to attend to the patient and review the CTG trace 3. If the CTG is suspicious or abnormal; a) Put patient in the left lateral position b) Stop oxytocin drip c) Give nasal oxygen 5L/min or give oxygen through ventimask d) Inform the medical officer or registrar/specialist as soon as the suspicious trace is detectedWHEN TO USE INTERNAL CTG: 1. When the trace from the external CTG monitoring is difficult to interpret due to intermittent loss of tracing. This could occur if the patient is agitated or in pain and they move constantly causing the loss of trace or in obese patients and in the second stage of labour. 2. Twin or multiple pregnancy  All non-reactive CTG should be informed to Medical officer (MO) or specialist  House officer (HO) should not decide on the management of non-reactive CTG without consulting Medical Officer or Specialist  All CTG traces should have the patient’s name and NRIC, interpretation of the trace, the doctor’s signature and time.  CTG traces are legal documents! Keep it safely and document appropriately! 81Department of O&G, Sarawak General Hospital
  • 82. Interpretation of CTGA. Normal CTG trace: • Baseline heart rate : 110- 160 bpm • Baseline variability : 10-25 bpm • Accelerations: 2 or more in 20 minutes. Increase > 15 bpm lasting at least 15 sec • Decelerations : AbsentB. Suspicious CTG trace: • Accelerations: absent for > 40 minutes and any of the following: • Baseline heart rate : bradycardia <110 bpm tachycardia >160bpm • Baseline variability : <10 bpm lasting for > 40 minutes, greater significance if <5 bpm. • Decelerations : variable decelerations without ominous featuresC. Abnormal CTG trace: • Accelerations absent for > 40 minutes; and any of the following: • Abnormal baseline rate • Poor baseline variability of less than 5 bpm lasting over 90 minutes • Repetitive decelerations: late or variable • The features of decelerations which may indicate a poorer outcome includes; prolonged decelerations longer than 60 seconds, how low the FHR goes down and the delay in recovery. • Other specific traces categorized as abnormal are: 1. Sinusoidal pattern 2. Prolonged bradycardia (<100 bpm) for > 3 minutes 3 Shallow decelerations in the presence of markedly reduced baseline variability (< 5 bpm) in a non-reactive trace. The plan of management for patients with abnormal CTG is dependent on various factors such as the severity of the abnormal trace, the patient’s age and parity, how advance she is in labour, progress of labour, colour of the liquor, the risk level of her pregnancy and last but not least the patient’s opinion. 82Department of O&G, Sarawak General Hospital
  • 83. FETAL SCALP BLOOD SAMPLING:Fetal scalp pH testing is essentially an invasive vaginal procedure performed when awoman is in active labour to determine if the baby is getting enough oxygen.How the Test is Performed 1. Make sure it is technically possible before offering the test (Os > 4 cm dilated) 2. Membrane should be absent (SROM or ARM) 3. Make sure there is someone skilled in performing the procedure 4. Make sure the blood gas machine is functioning 5. Make sure the various instruments are available 6. Counsel the mother regarding the test: a) Why it needs to be done b) How it is going to be done c) How long it is going to take (5 to 10 minutes) d) Who is going to do it e) What the results would mean f) The risks to the baby g) Inform her that there is a possibility of failure (which invariably means revert to caesarean section) 7. The mother lies on her back in the lithotomy position 8. Her legs/feet should be in stirrups 9. Insert an appropriate sized metal or plastic cone into the vagina 10. The cone should fit snugly against the scalp of the fetus 11. The scalp of the fetus is cleaned, wiped dry and pierced with a 2mm scalp blade at the end of a long blade holder. 12. A small amount of blood is then withdrawn using a special heparinised thin tube. 13. Make sure that you obtain enough blood at least half the length of the tube. 14. The blood is then analyzed by the blood gas machine in the labour ward 15. The result would be available within a few minutes. Fetal scalp blood sampling where available and if technically possible should be performed before a decision for caesarean section is made in cases where CTG changes are not conclusive or noted as suspiciousNormal fetal blood sample results:  Normal pH: 7.25 - 7.35  Borderline pH: 7.20 - 7.25  Abnormal pH: < 7.20 83Department of O&G, Sarawak General Hospital
  • 84. What the results mean: 1. An abnormal pH of less than 7 means that delivery have to be expedited either by instrumental delivery if all prerequisites are fulfilled or by caesarean section 2. A borderline result may necessitate a repeat test or several repeat tests if a decision is made to allow the labour to continue. This should be undertaken after the patient is counseled by the registrar/specialist and is agreeable with this plan of management. This should be recorded clearly in the notes. The test is usually repeated every 30 minutes until delivery. 3. Decision to continue with labour when the result is borderline should be undertaken only if vaginal delivery is expected soon 4. Normal result means the abnormality noted on the CTG is probably not significant. Repeat test is usually not required unless there are further adverse changes on the CTG. 5. The test results is a guide, the decision as in abnormal CTG, should be undertaken with all associated factors taken into account.Risks of this procedure include the following: 1. Continued bleeding from the puncture site (more likely if the fetus has a pH imbalance) 2. Infection 3. Bruising of the babys scalpConsiderations:This test is not recommended for mothers with: a. Infections, such as HIV or hepatitis C. b. Thrombocytopaenia c. Non cephalic presentation 84Department of O&G, Sarawak General Hospital
  • 85. 1.4.5 PAIN RELIEF IN LABOUR_____________________________________________________________________________________1. Ensure adequate pain relief for patients in labour.2. Discuss choice of analgesia to identify the patients preference.3. Ideally, the choice of analgesia during labour should be discussed with the patient during antenatal period.OPTIONS1. Parenteral analgesia (Intramuscular pethidine)2. Inhalation analgesia3. Epidural analgesiaPARENTERAL ANALGESIA1. Pre-requisite: 1.1 Normal BP 1.2 Reactive CTG2. Intramuscular pethidine: 2.1 Normal dose 75-100 mg 2.2 1 mg per kg body weight 6 hourly3. Combined (for anti-emetic effect) with Metoclopramide (Maxolon) l0mg or promethazine HCL (phenergan) 25mg.4. Imminent delivery should not be regarded as an indication to withold IM Pethidine (provided CTG is reactive).5. If pethidine is given to the mother, the newborn may suffer from respiratory depression. NOTE: Naloxone: antidote for pethidine  Administer to baby Intramuscular Naloxone 0.1mg/kg body weight. Repeated doses maybe required to prevent recurrent respiratory depression.  1 Ampoule of Naloxone = 1 ml = 0.4 mg 85Department of O&G, Sarawak General Hospital
  • 86. INHALATION ANALGESIA 1. Safe for mother and fetus. 2. Mixture of Oxygen ( 50% ) and Nitrous Oxide ( 50% )- ENTONOX 3. Effective only when used correctly. 4. Mask must be placed over patients face correctly. 5. Clean mask for each patient. 6. Instruct patient to start breathing the gas (normal rate but deep breath) as the patient feels tightening of the uterus (because Entonox has a latent period of 15 seconds). 7. To continue breathing in Entonox till pain ceases. 8. Not effective if patient starts inhalation at the point when the pain starts.EPIDURAL ANALGESIA1. To liaise with anaesthetist if a patient request / requires epidural analgesia.2. Consider this when effective analgesia is required in patients with heart disease, multiple pregnancy.3. Choice of analgesia offered should be discussed with mothers during antenatal period.4. Refer to the chapter on Guidelines for Epidural Anaesthesia in Women on Thromboprophylaxis . 86Department of O&G, Sarawak General Hospital
  • 87. 2.5 PROBLEMS ASSOCIATED WITH DELIVERY2.5.10 Episiotomy2.5.11 Repair of cervical tears2.5.12 Repair of vaginal and perineal tears2.5.13 Instrumental delivery2.5.14 Management of retained placenta2.5.15 Preterm prelabour rupture of membranes (PPROM)2.5.16 Prelabour rupture of membranes (PROM)2.5.17 Perinatal Group B Streptococcus Infection Prevention2.5.18 Preterm labour 2.5.9.4 Tocolytic for preterm labour 2.5.9.5 Tocolytic regime: Nifedipine 2.5.9.6 Tocolytic regime: Salbutamol2.5.10 Antepartum haemorrhage 2.5.10.3 APH: Abruptio placenta 2.5.10.4 APH: Placenta praevia2.5.13 Postpartum haemorrhage2.5.14 Guidelines for transfusion in massive blood loss2.5.13 Disseminated intravascular coagulation (DIVC) 2.5.13.1 Use of factor 7 (Novo 7)2.5.14 Uterine inversion2.5.15 Cord prolapse2.5.l6 Shoulder dystocia 87Department of O&G, Sarawak General Hospital
  • 88. 2.5.1 EPISIOTOMY______________________________________________________  NO ROUTINE EPISIOTOMY EVEN FOR PRIMIGRAVIDA  EPISIOTOMY RATE TARGET FOR EVERY HOSPITAL IS < 30%Indications to consider episiotomy: 1. Complicated vaginal deliveries such as breech, shoulder dystocia, instrumental deliveries. 2. Scarring resulting from female genital cutting / mutilation or poorly healed third or fourth degree tears. 3. Fetal distress.Procedures:1. Apply general aseptic precautions.2. Adequate analgesic in the form "of local infiltration with lignocaine or pudendal block unless epidural analgesic in situ.3. Infiltrate 10 ml 0.5% lignocaine solution beneath the vaginal mucosa, beneath the perineal skin and deeply into the perineal muscle.4. Anaesthetize early to provide sufficient time for effect.5. Perform episiotomy when: 5.1 The perineum is thinned out; 5.2 3-4 cm of the babys head is visible during contraction. 6. Place two fingers between the babys head and the perineum and cut the perineum with scissors, about 3-4 cm in the mediolateral direction. 7. After delivery, examine for any extension and other tears.REPAIR OF EPISIOTOMY1. Material preferred is absorbable synthetic material polyglycolic acid, over chromic catgut as the former is associated with less perineal pain, analgesic use, dehiscence and re-suturing.2. Vaginal mucosa is closed with continuous 2/0 suture: 2.1 Start about 1 cm above the apex, continue the suture to the level of the vaginal opening. 2.2 At the opening of the vagina, bring together the cut edges of the vagina.3. Close the perineal muscle using interrupted 2/0 sutures.4. Close the skin using interrupted or subcutilar 2/0 sutures. Continuous subcuticular technique is associated with less short term pain. 88Department of O&G, Sarawak General Hospital
  • 89. COMPLICATIONS OF EPISIOTOMY1. Vulval/vaginal haematoma management depends on size and if it is increasing in size. Small haematomas should be managed conservatively. Bigger haematoma needs to be drained, bleeders secured and a drain should inserted at the end of the procedure.2. In perineal wound breakdown, assess the wound: 2.1 If there are signs of infection, do regular dressing until it is clean then perform secondary suturing if necessary 2.2 If clean, secondary suturing can be performed3. For mild infection, antibiotics are not required4. In severe infection a combination of oral antibiotics is required for 7 days: 4.1 Tab cefuroxime 250 mg, 12 hourly 4.2 Plus Tab Metronidazole 400 mg, 8 hourly5. In deep infection involving muscles and is causing necrosis (necrotizing fasciitis), combined parenteral antibiotics is used until necrotic tissue has been removed and the patient remains afebrile for 48 hours: 5.1 IV Penicillin G 2 million units 6 hourly 5.2 Plus FV Gentamicin 5 mg/kg body weight, daily. 5.3 Plus IV Metronidazole 400 mg, 8 hourly.6. Once the patient is afebrile for 48 hours, switch to combined oral antibiotics for 7 days: 6.1 Tab cefuroxime 250 mg, 12 hourly 6.2 Plus Tab Metronidazole 400 mg, 8 hourly7. Necrotizing fasciitis requires wide debridement and secondary closure is performed in 2 - 4 weeks, pending resolution of the infection. 89Department of O&G, Sarawak General Hospital
  • 90. 2.5.2 REPAIR OF CERVICAL TEARS_______________________________________________________________________________________1. Apply general aseptic precautions.2. Adequate analgesic is required. Repair in OT under regional or general anesthesia is required and extensive tears.3. The assistant should apply fundal pressure to give better exposure of the cervical tears.4. Gently grasp the cervix with ring or sponge forceps on both sides of the tear and gently pull to expose the tear and to inspect the entire cervix.5. Start suturing from the apex with 0 chromic catgut or polyglycolic suture.6. Apply interrupted sutures along the entire length of the laceration about 1 cm apart, taking the whole thickness of each lip of the cervix.7. If the apex is difficult to reach and ligate, grasp the apex with artery or rin g forceps and leave it in place for 4 hours: 7.1 Open the forcep partially after 4 hours but do not remove 7.2 Remove the forceps completely after another 4 hours8. Laparotomy may be required to repair a cervical tear that has extended deep beyond the vaginal vault. 1. Repair should be performed in OT under general/regional anesthesia if:  If the patient has loss significantly and resuscitation is anticipated  Uncooperative patient  Extensive tear  Poor lighting in LW 2. Vaginal packing should be used only as a temporary measure to reduce bleeding from the cervix until haemostsis can be secured surgically or if repair cannot be undertaken and the patient has to be transferred to a specialist hospital. 90Department of O&G, Sarawak General Hospital
  • 91. 2.5.3 REPAIR OF VAGINAL AND PERINEAL TEARS______________________________________________________1. The different „degrees‟ of tears are: 1.1 First degree involving skin only; 1.2 Second degree involving perineal muscles; 1.3 Third degree involving partial or complete disruption of the anal sphincter 1.4 Fourth degree involving complete disruption of the external and internal sphincter and rectal mucosa.2. Absorbable synthetic material polyglycolic acid is preferred over chromic catgut for their tensile strength, non-allergic properties and lower probability of infectious complications. The former is associated with less perineal pain, analgesic use, dehiscence and re-suturing.REPAIR OF FIRST AND SECOND DEGREE TEARS1. Most first degree tears close spontaneously without sutures.2. The general aseptic precautions apply.3. Carefully examine the vagina, perineum and cervix.4. Exclude third or fourth degree tear by: 4.1 Place a gloved finger in the anus; 4.2 Gently lift the finger and identify the sphincter; 4.3 Feel for the tone or tightness of the sphincter.5. Change to clean gloves.6. If the sphincter is not injured, proceed with repair.7. Adequate analgesic by infiltrating beneath vaginal mucosa, beneath the skin of the perineum and deeply into the perineal muscle using about 10 ml 0.5% lignocaine solution. Anaesthetize early to provide sufficient time for effect.8. Repair the vaginal mucosa using a continuous 2/0 suture: 8.1 Start the repair about 1 cm above the apex of the vaginal tear, continue the suture to the level of the vaginal opening; 8.2 At the opening of the vagina, bring together the cut edges of the vaginal opening. 8.3 Bring the needle under the vaginal opening and out through the perineal tear and tie.8. Repair the perineal muscles using interrupted 2/0 suture. A second layer of stitch may be required to close the space in a deep tear. 91Department of O&G, Sarawak General Hospital
  • 92. 10. Skin is closed using sub-cuticular or interrupted 2/0 sutures starting at the vaginal opening. The former is associated with less short term pain.11. If the tear was deep, rectal examination is performed after the completion of the repair to ensure there are no stitches involving the rectal mucosa. REPAIR OF THIRD AND FOURTH DEGREE PERINEAL TEARS 1. Repair the tear in the operating room. 2. Prophylactic antibiotics (ampicillin and metronidazole) is required and continued orally for 1 week. 3. The general aseptic precautions apply. 4. Carefully examine the vagina, perineum and cervix. 5. Exclude third or fourth degree tear by: 5.1 Place a gloved finger in the anus. 5.2 Gently lift the finger and identify the sphincter or the lack of it . 5.3 Feel the surface of the rectum and look carefully for a tear. 6. Change to clean gloves. Pudendal block or ketamine may be used. If all edges of the tear can be seen, the repair can be done using local infiltration with lignocaine and pethidine and diazepam IV slowly. 8. Adequate analgesic by infiltrating beneath vaginal mucosa, beneath the skin of the perineum and deeply into the perineal muscle using about 10 ml 0.5% lignocaine solution. Anaesthetize early to provide sufficient rime for effect. 9. Repair the rectum using interrupted 2/0 or 3/0 PDS suture 0.5 cm apart to bring together the mucosa. The sutures are placed through the muscularis and not all the way through the mucosa: 9.1 Cover the muscularis layer by bringing together the fascia! layer with interrupted sutures. 9.2 Apply antiseptic solution to the area frequently.10. If the sphincter is torn: 10.1 Grasp each end of the sphincter with an Allis clamp 10.2 Repair the sphincter with 2 or 3 interrupted stitches of 2/0 suture. 11. Apply antiseptic solution to the area again and re-examine the anus with a gloved finger to ensure the correct repair of the rectum and sphincter. 12. Change to clean gloves. 13. Continue repairing the vaginal mucosa, perineal muscles and skin. 92Department of O&G, Sarawak General Hospital
  • 93. POST-PROCEDURE CARE 1. Patient should be followed up closely for signs of infection. 2. Avoid giving enemas or rectal examinations for 2 weeks. 3. Give stool softener by mouth for 2 week. 4. Give oral antibiotics for 1 week, e.g. Augmentin 625 mg 12 hourly 5. Review in clinic in 2-4 weeks to examine wound 6. Ask if she has fecal incontinence, rectal pain and urgencyMANAGEMENT OF NEGLECTED CASES OF 3RD & 4TH DEGREE TEARSIf closure is delayed for more than 12 hours, infection is inevitable as a perineal tearis always contaminated with faecal material. As such, delayed primary closure isindicated:1. For first and second degree tears, leave the wound open.2. For third and fourth degree tears, close the rectal mucosa with some supporting tissue and approximate the fascia of the anal sphincter with 2 or 3 sutures. Close the muscle and vaginal mucosa and the perineal skin 6 days later.  Faecal incontinence may result from complete sphincter transection. Many women are able to maintain control of defaecation by the use of other perineal muscles. When incontinence persists, reconstructive surgery must be undertaken at 3 months or more after delivery.  Rectovaginal fistula requires reconstructive surgery 3 months or more after delivery.  The role of vaginal packing is limited to reducing blood loss while waiting for definitive management of multiple vaginal tears/lacerations: i. Transferring patient to a specialist hospital ii. While waiting for OT to call the patient for EUA and repair of the multiple vaginal tears  Vaginal packs soaked with a mixture of acriflavine and diluted adrenalin should be used for packing  The Vagina should only be lightly packed to avoid further tears  Vaginal packs should be removed within 4 to 6 hours. 93Department of O&G, Sarawak General Hospital
  • 94. 2.5.4 INSTRUMENTAL DELIVERY______________________________________________________PRE-REQUISITE:1. Head should not be palpable per abdomen active uterus - presence of uterine contractions.2. Empty bladder - catheterize bladder if patient has not passed urine correctly.3. No membrane (Amniotic membranes must have been ruptured)4. Full OS: Cervical OS must be fully dilated.5. Cephalic with no excessive caput or moulding.6. Position must be determined and favorable for instrumental delivery.7. An adequate bony pelvis.8. Adequate analgesia.9. Paediatric doctor to standby for delivery (before instrument is applied).10. Doctor must be experienced in performing the instrumental delivery (logged experience required). Otherwise have to be supervised.11. CPD ruled out.12. Operator must know his limitation and be prepared to abandon the procedure in case of difficulty.13. The use force is the worst of the available option.14. Instrumental deliveries should NOT be attempted because of non-availability of OT - inform specialist to request for second OT.15. A negative attempt should be swiftly converted to abdominal delivery.16. The specialist must be informed about a failed instrumental deliveryDO NOT ATTEMPT INSTRUMENTAL DELIVERY IF: 1. HEAD PALPABLE PER ABDOMEN 2. UNABLE TO DEFINE POSITION 3. ESTIMATED FETAL WEIGHT > 3.8 KG 4. INEXPERIENCEDREMEMBER:  IT SHOULD NOT BE A VAGINAL DELIVERY AT ALL COST!  ATTEMPT INSTRUMENTAL DELIVERY ONLY IF ALL PRE-REQUISITES ARE FULFILLED  ATTEMPT INSTRUMENTAL DELIVERY ONLY IF YOU KNOW HOW, UNLESS SUPERVISED. 94Department of O&G, Sarawak General Hospital
  • 95. POST PROCEDURE:1. Proper documentation in the case note2. All post-instrumental babies should not be discharged within the first 24 hours.3. Urinary and anal sphincter dysfunction must be excluded before patient is discharged4. If PPH, do FBC before discharge.5. It is encouraged that the registrar who performs the instrumental delivery must review the patient in post natal ward. 6. It is preferable that these patients are reviewed in our post-natal clinic at 6 weeks. This is to ensure that these patients do not suffer from urinary/bowel problems. 95Department of O&G, Sarawak General Hospital
  • 96. 2.5.5 MANAGEMENT OF RETAINED PLACENTA_______________________________________________________________________________________Diagnosis:1. Not able to deliver placenta by CCT within 30 minutes of delivery of fetus.2. Ensure that before making a diagnosis of retained placenta: 2.1 Bladder is catheterized 2.2 Syntometrine has been given 2.3 Sufficient time is allowed3. Snapping of the cord during CCT is not equivalent to retained placenta.Pre-requisite:1. Inform registrar.2. Inform/counsel patient regarding manual removal of placenta (MRP).3. Set IV line.4. Group and cross match 2 units of whole blood (do not have to wait for blood before carrying out the procedure).5. BP/PR.-Baseline, and then continue monitoring during procedure and thereafter.6. Resuscitate patient if she is in shock. MRP SHOULD BE DONE IN OT UNDER GENERAL OR REGIONAL ANESTHESIAPROCEDURE:1. Aseptic technique.2. Sterile gown.3. Long gloves.4. PROPHYLACTIC ANTIBIOTIC- Stat dose of IV ampicillin 1 gm and IV metronidazole 5OOmg.5. Left hand should grasp the uterus- per abdomen.6. Right hand introduced through the vagina into the uterus.7. If OS is closed- use fingers to dilate (be patient).8. If cord is intact- use it as a guide to the placenta9. Identify the edge of the placenta.10. Introduce the edge of your palm between the placenta and the uterine wall.11. Side to side motion to separate the placenta.12. Fingers always pointing into the uterine cavity- away from the uterine wall.13. Do not remove your hand until the placenta is entirely detached.14. Check the placenta for complete removal-if not re-explore. 96Department of O&G, Sarawak General Hospital
  • 97. 15. Give IV ergometrine O.5mg or IV syntocinon 10 units.16. External uterine massage - ensure uterus is well contracted.17. IV syntocinon (40 units in 500mls of Ringers lactate) over 6 hours.18. Inspect vagina after procedure to identify vaginal wall tears or episiotomy wound if tears are extensive, the registrar must carry out the repair.19. Observe patient for a minimum of 1 hour, till patient is stable before transfer to post natal ward.POST PROCEDURE1. Document the procedure, should include the following information: 1.1 Placenta/membranes: complete/incomplete/ragged edges; 1.2 Estimated blood loss.2. Monitor patient in labour room till sedation has worn off or at least 1 hour.3. Palpate uterus during observation to ensure that it remains contracted.4. Maintain infusion of IV fluids.5 KIV blood transfusion.6. If PPH, check FBC and coagulation profile7. Give broad spectrum oral antibiotics for 7 days 97Department of O&G, Sarawak General Hospital
  • 98. 2.5.6 PRETERM PRELABOUR RUPTURE OF MEMBRANES (PPROM)_______________________________________________________________________________________Defined as the spontaneous rupture of membranes before the onset of regularuterine contractions which occurs prior to completed 37 weeks POA.DEFINITION 1. Less than 37 completed weeks of gestation. 2. Spontaneous rupture of membranes. 3. No uterine contraction / not in labour.OFTEN ASSOCIATED WITH:1. Infection.2. Polyhydramnios.3. Unstable lie.4. Multiple pregnancy. !CLINICAL EXAMINATION: (Determine period of gestation)1. Abdominal examination: Symphysio-fundal height, lie/presentation, presence of any contraction.2. Diagnostic sterile speculum examination: 2.1 Confirm diagnosis 2.2 Assessment of the cervix 2.3 Low vaginal swab for C&S3. Rule out cord prolapse.4. Vaginal examination to note status of cervix (not recommended).Unnecessary VE increases risk of infection!Speculum examination may demonstrate fluid coming from cervix or forming a pool inthe posterior fornix. Encourage patient to cough in order to demonstrate a gush of fluid.Red litmus pH paper would turn blue if there is presence of amniotic fluid (alkaline). CHORIOAMNIONITIS: 1. Fever >37.5°C 2. And 2 other criteria: Maternal tachycardia Uterine tenderness Fetal tachycardia Foul smelling amniotic fluid Leukocytosis 98Department of O&G, Sarawak General Hospital
  • 99. IF DIAGNOSIS OF PPROM IS CONFIRMED: 1. Admit patientMONITORING: 1. Temperature and vital signs monitoring charts (4 hourly). 2. Uterine contraction/tenderness. 3. Strict pad chart: note volume and colour of liquor. 4. High vaginal swab for C&S during admission: trace result early. 5. Twice weekly WBC. 6. Fortnightly growth scans.MANAGEMENT: A. LESS THAN 34 WEEKS POA 1. Start T. EES 400mg BD for 10 days. 2. Antenatal steroids 3. Give tocolytics if patient is in labour for dexamethasone to work provided no evidence of chorioamnionitis. 4. Monitor mother and fetus. 5. Allow labour if steroid therapy has been completed. 6. Expectant management up to 34 weeks if patient does not go into labour. 7. If infection develops, start on parenteral antibiotics and deliver fetus (choice of antibiotic to be discussed with the specialist). 8. Attempt vaginal delivery if patient in established labour. 9. If caesarean section is performed, pack pelvic gutters to contain spread of infection. 10. Presence of chorioamnionitis: 10.1 Delivery is the best option irrespective of maturity of the fetus. 10.2 Must be treated with: 10.2.1 IV cefuroxime 750mg 8 hourly. 10.2.2 IV metronidazole 500 mg 8 hourly. 10.2.3 All antimicrobials are continued till afebrile for 24-48 hours; then switch to oral antimicrobials. 10.3 Newborn baby to be reviewed by the paediatric team. B. 34 WEEKS POA ONWARDS 1. Deliver after completion of dexamethasone providing there is no suspicion of chorioamnionitis 2. NICE Guidelines recommend delivery as the risk of managing such cases conservatively is higher than delivery 3. However, there should be a good neonatal care support in the hospital 4. In the district hospitals of Sarawak, cases of PPROM have to be referred to the nearest specialist hospital for further management 99Department of O&G, Sarawak General Hospital
  • 100. 2.5.7 PRELABOUR RUPTURE OF MEMBRANES AT TERM (PROM)_______________________________________________________________________________________Spontaneous rupture of membranes before the onset of regular uterine contractionswhich occurring after 37completed weeks of gestation.DEFINITION1. Completed 37 weeks gestation and beyond.2. Spontaneous rupture of membranes.3. No uterine contraction, not in labour.EXAMINATION1. Uterine fundal height.2. Speculum examination: demonstration of liquor, to rule out cord prolapse.3. High vaginal swab for C&S during admission.4. Vaginal examination to note status of cervix (cervical scores).UPON ADMISSION1. CTG.2. WBC - if for conservative management (see below).3. Pad chart.4. Temperature and vital signs monitoring charts.MANAGEMENT OPTIONS1. Active management: IOL upon admission and assessment2. Conservative management: Allow 12-24 hours for spontaneous onset of labour; failing which for IOL (after 12 hours in SGH). 2.1 Bishop score favourable : ARM/Oxytocin induction 2.2 Bishop score not favourable : Cervical ripening with Prostin follow by ARM / Oxytocin 6 hours later. (1 prostin insertion only in SGH)3. Malpresentation / Abnormal lie: Emergency LSCS 100Department of O&G, Sarawak General Hospital
  • 101. 2.5.8 PERINATAL GROUP B STREPTOCOCCUS INFECTION PREVENTION______________________________________________________Maternal GBS colonization is associated with an increased risk of PPROM and pretermlabour. However the diagnosis and treatment of the infection has not shown to reduce thisrisk. GBS is a vaginal commensal, the carrier rate has been cited to be between 10 - 25%.  Congenital infection of the newborn secondary to this pathogen carry significant morbidity and mortalityDetection1. All patients who are admitted for preterm prelabour rupture of membranes (PPROM) / prelabour rupture of membranes (PROM) must have a low vaginal swab culture to detect GBS.2. Culture swabs of the lower vagina and rectum has been shown to yield higher colonization rates in comparison to those taken from the cervix or higher vagina.Antepartum Prophylaxis:There are only a few indications for antepartum antibiotic prophylaxis: 1. Proven carrier planned for any procedure eg. cervical cerclage 2. Symptomatic pregnant women 3. Heavy colonization as evidenced by positive urine culture for GBS.Routine antepartum prophylaxis is not recommended as: 1. This may cause antibiotic resistance 2. This intervention has not proven to eradicate GBS totally at term / when the woman is in labour.Intrapartum Prophylaxis 1. Intravenous antibiotics to be given when patient is in labour (intrapartum antimicrobial prophylaxis). 2. Antibiotics: IV ampicillin 2 gm stat then 1 gm 4 hourly, unless culture results indicate otherwise. In the presence of allergy to penicillin: use Clindamycin 900 mg, 8 hourly. 101Department of O&G, Sarawak General Hospital
  • 102. Antibiotics should be given to a patient with:1. PPROM with positive culture.2. PPROM that has been managed actively (planned for delivery).3. PROM exceeding 18 hours (> 12 hours in SGH), and PPROM > 12 hours4. In labour with positive antenatal culture.5. Presence of signs and symptoms of chorioamnionitis.6. History of previous baby been affected by GBS.Suspect chorioamnionitis in women with:1. Fever2. Uterine tenderness or uterine irritability3. Foul smelling vaginal discharge4. Leukocytosis5. Maternal tachycardia6. Fetal tachycardia7. Meconeum stained liqour 102Department of O&G, Sarawak General Hospital
  • 103. 2.5.9 PRETERM LABOUR__________________________________________________DIAGNOSIS1. Uterine contraction: 1.1 Occurring once every 10 minutes. 1.2 Lasting at least 30 seconds.2. Gestation before 37 completed weeks3. Vaginal examination finding: with or without cervical changes.INITIAL ASSESSMENT1. General condition of patient including her cardiovascular and thyroid status.2. Identity predisposing factor or causes: 2.1 PPROM 2.2 Infection 2.3 Abruption 2.4 Multiple pregnancy 2.5 Fetal anomaly3. Abdominal examination: SFH/Lie of fetus.4. Ultrasound scan: 4.1 Fetal condition (anomaly/viability) 4.2 Placental site 4.3 Amniotic fluid index5. Vaginal examination6. Transvaginal scan to assess cervical length (SGH). PLAN OF MANAGEMENT 1. To ensure best fetal outcome: Tocolysis to suppress labour in order to give antenatal steroid (IM Dexamethasone 12mg 12hrly x 2 doses) if less than 36 weeks 2. Consider delivery: 2.1 In the presence of infection 2.2 Interauterine death 2.3 Fetal abnormality 2.4 Steroid therapy completed 2.5 Unsuccessful tocolysis 3. Counsel patient regarding her condition and plan of management. 4. Paediatrics team to be informed if delivery is imminent, especially when ventilator may be required. 103Department of O&G, Sarawak General Hospital
  • 104. DELIVERY1. Allow vaginal delivery if cephalic presentation.2. Breech more than 1 kg- for Caesarean Section (Less than 1 kg need specialist input)3. To be conducted by doctor4. Episiotomy.5. Paediatric medical officer to stand by for delivery.6. Instrumental delivery - for obstetric indication only.7. Ventouse delivery not recommended for POA less than 36 weeksANTENATAL STEROID THERAPY 1) Repeated doses of dexamethasone are not recommended. Consult Obstetrician should the patient require repeated doses 2) Each completed dose of dexamethasone should be effective for 7 days 3) Allow 12 hours following 2nd dose if planned for delivery. 4) There is benefit of steroid if it has been administered for a minimum of 4 hours from the first dose. 5) Dexamethasone may cause transient poor glycaemic control 6) Dexamethasone should be given before delivery between 24 weeks to 36 weeks unless the risk to the mother or fetus outweighs the benefit (e.g. chorioamnionitis, acute fetal distress, acute massive APH) 7) Consider giving insulin on a sliding scale for patients in insulin1.5.9.1 TOCOLYSIS FOR PRETERM LABOURAIMThe aim of suppressing preterm labour is to allow time for:1. completion of antenatal steroid therapy (24hr from 1st dose);2. in-utero transfer to a another hospital for the benefit of baby if no contraindication for the delay in delivery.3. To allow the pregnancy to continue and reduce the risk of prematurityPREREQUISITE BEFORE INITIATION OF TOCOLYTIC REGIME1. Normal viable fetus2. No maternal medical contraindication for labour suppression3. Normal maternal ECG4. Baseline random blood sugar level (RBS)5. Baseline serum electrolytes (BUSE) 104Department of O&G, Sarawak General Hospital
  • 105. CONTRAINDICATIONS 1. Fetal compromise 2. Antepartum haemorrhage (APH) –absolute contraindication in abruption placenta 3. Intrauterine infections (chorioamnionitis) 4. Maternal cardiac disease 5. Hyperthyroidism 6. Intrauterine disease 7. Advanced labour 8. Severe hypertension 9. Multiple pregnancy (relative contraindication) 10. Poorly controlled diabetes TOCOLYTIC AGENTS:  Nifedepine (preferred).  Consider beta agonist if Nifedepine failed or not available. MONITOR FOR: Fetal tachycardia Palpitation Maternal tachycardia Headache Maternal pulmonary edema Hypokalemia Maternal hypotension HyperglycemiaTOCOLYTIC REGIME:2.5.9.2 NIFEDIPINE SUPRESSIONLoading dose:T.Nifedipine 15 mg stat then 15 mg every 15 minutes for 4 dosesMaintenance dose:T.Nifedipine 20 mg tds for 48 hoursMonitoring of patient on Nifedipine suppression: 1. Continuous monitoring of the fetal heart rate is recommended as long as the patient has contractions 2. Monitor blood pressure and pulse every 15 minutes for the first hour, then every 30 minutes for the 2nd hour then hourly during the first 24 hours. 105Department of O&G, Sarawak General Hospital
  • 106. Side effects of Nifedipine: 1. Tachycardia 2. Palpitations 3. Flushing 4. Headaches 5. Dizziness 6. Nausea 7. Hypotension is minimal if patient is normotensiveContraindication to Nifedipine suppression: 1. Allergy to nifedipine 2. Hypotension 3. Hepatic dysfunction 4. Concurrent use of beta-mimetics, transdermal nitrates or other antihypertensive medicationBased on available evidence nifedipine is superior to salbutamol as it is more tolerableand have a safer profile. The investigators found a reduced risk of delivery within 7 daysand at less than 34 weeks gestation. Cessation of treatment due to adverse reactionoccurred in 1 of 419 patients, versus 29 of 414 with other tocolytics. The nifedipine-treated neonates also had decreased risk of respiratory distress syndrome, necrotizingenterocolitis, and intraventricular hemorrhage.2.5.9.3 SALBUTAMOL SULFATE (VENTOLIN) 1. 1 ampule = 0.5 mg/1 ml 2. Dilute according to table below 3. Increasing at 15 minutes interval 4. Maximun 45 μg/min 5. Preferably to use infusion syringe pump instead of dropmet to avoid volume overload.Note: 1 ml = 20 drops, 1 dpm = 3 ml/hrMATERNAL AND FETAL MONITORING: 1. Maternal pulse (every 15 minutes) 2. Blood pressure 3. RBS (6 hourly) or glucometer 4-6 hrly 4. BUSE (potassium levels-daily) 5. Auscultation of lungs field 4hrly 6. Maternal temperature 4hrly 7. Contraction / labour progress chart 1/2hrly 8. Continuous cardiac monitoring 9. FHR ( not more than 180/minute ) 10. Input/output charting 106Department of O&G, Sarawak General Hospital
  • 107. Dosage in Infusion syringe pump Dropmat45μg/min 5 mg (10 ampule) + 40 ml Dextrose 5 mg + 500 ml Dextrose 5% or 5% or Normal Saline Normal Saline dpm ml/hr dpm ml/hr5 μg/min 1dpm 3ml/hr 10dpm 30ml/hr10 μg/min 2dpm 6ml/hr 20dpm 60ml/hr15 μg/min 3dpm 9ml/hr 30dpm 90ml/hr20 μg/min 4dpm 12ml/hr 40dpm 120ml/hr25 μg/min 5dpm 15ml/hr 50dpm 150 ml/hr30 μg/min 6dpm 18ml/hr 60dpm 180ml/hr35 μg/min 7dpm 21ml/hr 70dpm 210ml/hr40 μg/min 8dpm 24ml/hr 80dpm 240ml/hr45 μg/min 9dpm 27ml/hr 90dpm 270ml/hrCESSATION OF TOCOLYSIS:1. Symptoms of intolerance to (3-agonist tocolytic agents - palpitation, severe tremor, chest pain, vomiting, severe headache and restlessness2. Sign & symptom of pulmonary oedema3. Maternal heart rate > 120 bpm4. FHR>180bpm5. Maternal DBF < 60mmHgMaintain infusion to complete administration of antenatal steroid or to achieve in-uterotransfer; before attempting to taper down the dose. Gradually wean every 30 minutes.Maximum duration of infusion: 24 hours  No role for maintenance tocolytics  Minimize vaginal examinations to reduce risk of infection  Benefits of suppression of labour have to outweigh possible risks 107Department of O&G, Sarawak General Hospital
  • 108. 2.5.10 ANTEPARTUM HAEMORRHAGE______________________________________________________TWO GROUPS OF PATIENTS WILL BE SEEN IN THE LABOUR ROOM: 1. Direct admission (booked or unbooked) 2. Booked patient (in-patient, with placenta praevia)RESUSCITATE PATIENTDo a quick assessment of her vital signs first and if required resuscitate the patient (Seebelow)ASSESS PREGNANCY 1. Period of amenorrhoea 2. Uterine size & activity 3. Viability of fetus, lie and presentation 4. Placental localization if not previously done. 5. No digital examination till placenta praevia is ruled out by ultrasound scan 6. Further management after discussing with specialist 7. Proceed to perform digital examination after ruling out placenta praevia.Causes of APH (bleeding >22 weeks gestation)1. Abruption placenta2. Placenta praevia3. Indeterminate APH4. Local causes2.5.10.1 APH: ABRUPTIO PLACENTATHE PREMATURE SEPARATION OF A NORMALLY LOCATED PLACENTA FROM THEUTERUS PRIOR TO THE DELIVERY OF THE FETUSPrinciple of management1. Assess maternal status: 1.1 Evaluate amount of blood loss 1.2 Coagulation status2. Analgesia3. Assess fetal status 3.1 Gestational age 3.2 Viability 3.3 Lie / presentation4. Plan for delivery 108Department of O&G, Sarawak General Hospital
  • 109. ASSESS PATIENT 1. Blood pressure 2. Pulse rate 3. Blood Loss (beware of concealed bleed) 4. Fetal condition 5. Check coagulation profile INVESTIGATION 1. FBC 2. Coagulation profile 3. Renal profile 4. Group and cross match RESUSCITATE PATIENT 1. Call for Red Alert Team if necessary. 2. Site 2(two) large bore (14G/16G) intravenous access lines for fluid resuscitation. 3. Transfuse fresh blood/blood components. 4. Correct coagulopathy if any. 5. Oxygen therapy (5L/min through ventimask). 6. CBD: to assess renal function / hydration.DELIVERY PLAN: Abruptio Placenta Unfavourable cervix Favourable cervix Viable fetus Intrauterine death Fetal distress Live baby with reactive CTG Other obstetric indications FOR VAGINAL DELIVERY FOR CAESAREAN SECTION Fetal distress, slow progress, patient bleeding ++  Keep patient / next of kin informed of progress  Anticipate PPH  Abruptio placenta is a clinical diagnosis 109Department of O&G, Sarawak General Hospital
  • 110. 2.5.10.2 APH: PLACENTAE PRAEVIAA PLACENTAE WHICH IS IMPLANTED PARTIALLY OR ENTIRELY IN THE LOWERSEGMENT OF THE UTERUSASSESS PATIENT1. Blood pressure & pulse rate2. Estimate blood loss (refer to blood loss pictogram)3. Fetal condition & well being, CTG4. Do not do vaginal examination (if diagnosis is confirmed)5. Ultrasound scan examination only done after stabilizing the patient6. Selected patient may require speculum examination (when patient has been stabilized) to rule out cervical causes of bleedingRESUSCITATE PATIENT 1. Refer to „resuscitate patient‟ above 2. Keep patient nil orally for the first 12 hours even if patient had only tell tale bleeding.MANAGEMENT / DELIVERYDecision for delivery is based on quantity and continuity of bleed irrespective of fetalviability or maturity. MANAGEMENT Light Heavy and continuous bleeding/bleeding stop bleeding Conservative Mx if For imminent delivery by For delivery if LSCS Premature baby To complete antenatal LSCS by experienced steroid surgeon in specialist Correct anaemia Fetus > 36 weeks hospital GXM blood 110Department of O&G, Sarawak General Hospital
  • 111. 2.5.11 POSTPARTUM HAEMORRHAGE_____________________________________________________________________________Most patients compensate with blood loss of up to 1000ml. A watchful approachwith anticipation can prevent life-threatening situation.Definitions1. Primary PPH : Blood loss >500 ml within 24 hours of delivery2. Secondary PPH : Abnormal blood loss after 24 hour of delivery3. Massive haemorrhage : Blood loss > 1500ml / > 30% blood volume  Timing is vital in management of PPH  Early involvement of consultant and appropriate intervention can safe lifeCLINICAL ASSESSMENT OF BLOOD LOSS:Blood loss (% of blood MAP Clinical effectsvolume) Postural hypotension500 ml-1000ml (10-15 %) Normal Mild tachycardia Tachycardia1000-1500 ml (15-30%) Slight fall Thirst Weakness Tachycardia1500ml-2000ml (30-40%) 50-70 mmhg Pallor Oligoria Confusion Restlessness Tachycardia> 2000 ml (> 40%) < 50 mmhg Anuria Air hunger Coma Death 111Department of O&G, Sarawak General Hospital
  • 112. BLOOD PRESSURE ASSESSMENT BY PALPATION:Absent arterial pulsation SBP mmhgCarotid artery < 60Radial artery < 90Femoral artery < 80ESTABLISH CAUSE1. Quantify blood loss2. Rate of blood lossGENERAL ACTION PLAN1 CALL FOR HELP ( FED ALERT ).2. Site at least 2 large bore ( 14 G / 16 G ) intravenous lines.3. Monitor parameter ( Blood pressure/pulse rate/respiratory rate ) with pulse oxymeter.4. Group and cross match 4 units of whole blood or more with DIVC regime.5. 4-6 unit blood in case of massive haemorrhage.6. Blood sample for FBC/ coagulation profile.7. CBD to monitor urine output.8. Fluid replacement: 8.1 Start by infusing crystalloid (1-2 litres) 8.2 Followed by colloids (1 litre) 8.3 Give blood in appropriate cases9 CVP line in cases of massive haemorrhage. 10. Observe patient in labour room/HDW for a minimum of 6 hours before transfer to postnatal ward. 11. Massive haemorrhage may require longer period of observation in the labour room. 12. Oxygen via mask. 112Department of O&G, Sarawak General Hospital
  • 113. Management of PPH:  Resuscitation, monitoring, investigation and treatment should occur simultaneously  “SARAWAK PPH BOX” – where all the things you would need to manage a PPH is kept  “PPH CHART”- to monitor what was done and given during the management of PPH SPECIFIC CAUSE AND ACTION:a) UTERINE ATONY: 1. Massage uterus. 2. Check placenta to see if completely delivered. 3. Repeat Syntometrine. 4. Set up intravenous infusion of 40 units of Syntocinon, to repeat if necessary. 5. IM Carboprost 250mcg (Each ampule of Carboprost: 1 ml = 250 .g), if still not responsive to Syntocinon / Syntometrine. 6. Carboprost may be repeated after 15 minutes - maximum doses 2mg (8 ampoules). 7. However when 4 doses have been used and the patient is still leeding, consider Bakri balloons or if not available plan for surgical intervention. 8. If bleeding persists, uterus is still atony, to proceed for laparotomy: 8.1 Completed family - hysterectomy; 8.2 Not completed family - conservation approach, eg. internal iliac artery ligation;b) RETAINED PLACENTA: 1. MRP under sedation (See Manual Removal of Placenta). 2. Followed by Syntocinon intravenous infusion drip (40 units). 3. [f MRP fails, proceed to OT - Attempt MRP under GA. 4. If failed to proceed to laparotomy: 4.1 Completed family - hysterectomy; 4.2 Not completed family - conservation approach, eg. internal iliac artery ligation, B-Lynch suture 4.3 If bleeding persists - proceed to hysterectomy. 113Department of O&G, Sarawak General Hospital
  • 114. c) UTERINE INVERSION: (See uterine inversion)d) VULVAL/VAGINAL TEARS OR LACERATIONS: 1. Episiotomy/Vaginal laceration /Cervical tear. 2. Attempt immediate repair preferably under general anaesthesia. (See Repair of Cervical Tears)e) UTERINE TEARS OR RUPTURE: 1. Important to suspect there is a possibility of extended cervical or uterine tears or rupture based on clinical findings 2. EUA would be necessary 3. Exploratory laparotomy may be required and simple tears can be repaired 4. Hysterectomy maybe necessary 5. In district hospitals of Sarawak without O&G specialist, EUA can be counter productive. Consult specialist on call! 114Department of O&G, Sarawak General Hospital
  • 115. GUIDELINE OF MANAGEMENT AND PREVENTION OF POSTPARTUM HAEMORRHAGEPrevention: Active management of the 3rd stage of labour 1. IM Oxytocics (Ergometrine 500mcg/ Oxytocin 5 IU) given at the delivery of the anterior shoulder of the baby 2. Controlled cord traction (CCT) 3. Fundal/ Uterine MassageCauses of PPH: “The Four Ts” Tone (uterine atony) - COMMONEST Tissue (retained POC) Trauma (of the genital tract) Thrombin (coagulopathy)Management of PPH: Resuscitation, monitoring, investigation and treatment should occursimultaneously Major Obstetric haemorrhage EBL> 1500ml Continuing bleeding or clinical shock Call for help- Activate code red Inform O&G specialist on-call, Obstetric MO on-call, HOs, anaesthetic MO Resuscitation Airway, Breathing, Circulation Oxygen mask (15L/min) Fluid balance (2L Hartmann’s, 1.5L colloid) Blood transfusion (Group-specific blood or O RhD negative) Blood products (FFP, Platelet, cryoprecipitate, factor VIIa) Keep patient warm, Head bed down Monitoring and Investigations 14g cannula x 2 Medical treatment FBC, PT/PTT, BUSE, LFT Bimanual uterine massage GXM (4 units blood, FFP, Platelet, cryo) Empty bladder Foley catheter, Oxymeter, cardiac monitor IV pitocin 5 units bolus x2 Commence record chart IV/IM Ergometrine 0.5mg if BP normal IV Pitocin infusion (40 units/500ml N/S at Consider central and arterial lines 125ml/h) Estimate blood loss IM Haemabate 250 mcg every 15 minutes up to 8 Check placental completeness doses Intramyometrial haemabate 0.5mg OT- Is the uterus contracted? EUA- genital tract trauma, retained POC. Coagulopathy corrected? Transfer to tertiary centre? Intrauterine ballon tamponade (Rusch balloon, Bakri balloon, Foley catheter) All cases of PPH > 1000 Brace suture ml or cases that need IM Bilateral internal iliac ligation Carboprost need to Hysterectomy inform Specialist or Consultant stat (activate Consider ICU/HDU admission RED ALERT) Incident reporting Debriefing 115Department of O&G, Sarawak General Hospital
  • 116. QUICK GUIDE: MANAGEMENT OF PPH IN DISTRICT HOSPITALSREMEMBER the FOUR Ts for causes of PPH Tone (uterine atony) –95% Tissue (retained POC) Trauma (of the genital tract) Thrombin (coagulopathy)Resuscitation, monitoring, investigation and treatment should occur simultaneously PPH > 500 ml Call for help: In district hospital/clinics: MO, senior nurse, other nurses, blood bank/lab staff  RUB THE UTERUS UNTIL IT CONTRACTS…then continue rubbing  Oxygen 15L/min  Check vital signs: BP, PR, SpO2, Pulse volume  Set 2 – 16G brannula – send blood for GXM, FBC, PT/PTT, LFT & BUSE  Commence fluid resuscitation: N Saline alternate with colloids (Gelafundin)  Post-delivery IM Syntometrine given?  Start IV Pitocin 40 units in 500 ml N/S at 125 ml per hour  VE: Evacuate clots, any vaginal tears/lacerations?  Check: Placenta complete?  Insert CBD and monitor urine output  In KK or MCH: refer to either district hospital or specialist hospital depending on severity and if there is on-going loss (if uncertain, discuss with O&G specialist )  Estimate blood loss….STILL ACTIVELY BLEEDING? PPH>1000 ml  Continue bimanual uterine massage  Inform blood bank: NEED BLOOD URGENTLY!  Ambulance and driver on standby!  IV pitocin 5 units bolus x 2  Assess need for blood & blood products – GIVE BLOOD WHEN AVAILABLE  Ensure adequate resuscitation- correct coagulopathy if possible  Consult specialist in nearest specialist hospital early!  Still bleeding - IM Haemabate 250 mcg every 15 minutes up to 4 doses but if do not respond after 2 doses could move to next step (ensure patient is not asthmatic)  Insert Bakri‟s balloon as per protocol if uterus still atonic then……  Transfer patient to specialist hospital stat with escort  EUA for massive PPH - not advisable in district hospital  Refer to specialist & transfer to specialist hospital earlier if loss is too rapid and massive 116Department of O&G, Sarawak General Hospital
  • 117. COAGULOPATHY:1. Correct DIVC using blood/blood products (Refer to section on DIVC). 2. SARAWAK PPH BOX Inventory checklist(Please ensure all items are replenished after used)ITEM QuantityIV Cannula size 14, 16, 18 gauge 3 of each sizeIV drip set 3 unitsMicropore/ Plaster to secure cannula 3 rollsGelafundine 500ml 1 pintNormal saline 500ml 2 pintsOxytocin 10 iu/ml 10 ampoulesSyntometrine 2 ampoulesCarboprost/ Haemabate 250 mcg/ml 4 ampoules kept in the fridgeWater for injection 10ml 5 ampoulesSterile vaginal pack 3 packsSyringe 5ml, 10ml 3 of each sizeHypodermic Needle 21 (green), 23(blue) gauge 3 of each sizeBakri Balloon with manual 1 unitFoley catheter size 24F 2 unitsUrine bag 1 unit“ALL LW IN SARAWAK MUST HAVE A PPH BOX ON SITE” 117Department of O&G, Sarawak General Hospital
  • 118. 3. “PPH Management Checklist” Hospital/Clinic: _______________________ Date: __________________________ Patient‟s name: ___________________________ Age: __________________________ IC No: ____________________________ Time of call for help: ________ AM / PM Called by: _______________ Team Member Name Time arrivedInitial Management Time On-call O&G SpecialistOxygen given On-call MO On-call Anaesthetic MOHead bed down On-call AnaesthetistBrannula No. 1Brannula No. 2Brannula No. 3 Observations Fluids/blood/blood products Time Pulse BP Type Volume Time Blood sent Time FBC GXM units PT/PTT Placenta delivered Yes No Urinary catheter Drug Dose Time Syntometrine IM 1 ampule Ergometrine IM/IV 500mcg/ 1 amp (if normal BP) Oxytocin 40 units in 500ml N/S at 125ml/H Haemabate (Carboprost) IM 250 mcg/ 1amp Haemabate (Carboprost) IM 250 mcg/ 1amp Haemabate (Carboprost) IM 250 mcg/ 1amp Haemabate (Carboprost) IM 250 mcg/ 1amp Haemabate (Carboprost) IM 250 mcg/ 1amp Haemabate (Carboprost) IM 250 mcg/ 1amp Haemabate (Carboprost) IM 250 mcg/ 1amp Haemabate (Carboprost) IM 250 mcg/ 1amp Name O&G specialist called: ________________________ Time: ________ AM / PM (If from non-specialist hospital) Form filled by: Signature: “PPH management Check List” should be filled for every case of PPH” 118 Department of O&G, Sarawak General Hospital
  • 119. 2.5.12 GUIDELINES FOR TRANSFUSION IN MASSIVEBLOOD LOSS_____________________________________________________ObjectiveI. Restore circulating blood volume.2. Control bleeding.3. Maintain adequate blood oxygen transport capacity.4. To correct metabolic problems: acidosis, electrolyte imbalance, Ca+/K+.Treatment1. Replacement of blood loss using colloids / crystalloids initially, then blood and blood products with higher percentage blood volume loss.2. Colloid should not be transfused in the same IV line as blood.3. Normal saline should be transfused before blood.4. Control bleeding.5. Haemostasis: supportive therapy with components. 5.1 Cryoprecipitate to replace fibrinogen and Factor VII. 5.2 Platelets if there is D1VC. 5.3 FFP to replace other coagulation factors. 5.4 Red cell replacement for patients who have lost excessive blood.  Assess the antenatal patient’s risk for APH or PPH and take appropriate measures such as where to deliver, plan of delivery, anticipation of massive blood loss, taking steps to reduce risk and group and save or match the appropriate amount of blood.  Asking the blood bank how much blood or blood products they have in reserve for patients with a high risk of massive PPH is advisable. Blood bank should be inform of a any case with the potential of massive blood loss. 119Department of O&G, Sarawak General Hospital
  • 120. 1.5.13 DIVC_________________________________________________ANTICIPATE DIVC IN THE FOLLOWING CONDITIONS: 1. Massive / rapid blood loss (APH / PPH) 2. Abruptio placenta 3. Septicaemia / chorioamnionitis 4. Amniotic embolism 5. Pre-eclampsia 6. Intrauterine death 7. Missed abortion 8. Molar pregnancyCLINICAL SIGNS 1. Petechiae spots & ecchymosis 2. Bleeding from venepuncture site 3. Absence of clot formation in operative fieldBED SIDE TESTS (Academic) 1. Failure of blood in test tube to clot within 8 min__>_hypofibrinogenemia 2. Failure of clot to retract from the sides of the tube by the end of 1 hour > Thrombocytopenia 3. If the clots dissolves within 1 hour > Excessive fibrinolysis BIOCHEMICAL PARAMETERS 1. Low platelet 2. Prolonged PIT 3. Prolonged PT 4. Reduced/absent serum fibrinogen 5. Prolonged BT/CTMANAGEMENT:1. Call for help - initiate RED ALERT.2. Do not wait for biochemical evidence if clinically obvious.3. Involve blood bank personnel in management of cases (preferably the haematologist).4. Personnel to mobilize and coordinate to ensure availability of blood and blood products.5. Use whole blood while awaiting DIVC regime especially in massive hemorrhagic cases.6. Transfuse DIVC regime.7. If necessary repeat DIVC regime.8. Organize for HDU/ICU monitoring of patient - after stabilization. 120Department of O&G, Sarawak General Hospital
  • 121. 1 CYCLE OF DIVC REGIME: 1. Fresh frozen plasma 2 units 2. Platelet concentrate 4 units 3. Cryoprecipitate 6 unitsGUIDELINES FOR TRANSFUSION IN PATIENTS WITH DIVC1 Maintain circulatory volume - use crystalloids / colloids / plasma.2. Correct acidosis with sodium bicarbonate and hypoxia with oxygen.3. Replace missing coagulation factors with the following: 3.1 6 units of Cryoprecipitate over 10-20 minutes; 3.2 4 units of Platelets transfused within 1 hour; 3.3 2 units of Fresh Frozen Plasma. 3.4 Red cell transfusion as and when needed. 1 unit to raise HB by 1 g4. Evaluate response to therapy by monitoring: 4.1 Coagulation profile - PT/APTT, fibrinogen, platelet count, FDP. 4.2 If no laboratory test available, assess clinically by looking for: 4.2.1 Excessive bleeding from wound; 4.2.2 Oozing from venepuncture sites and raw area; 4.2.3 Evidence of new purpura / bleeding. 4.3 Repeat treatment with components if haemostasis is not secured.2.5.13.1 Guideline for use of recombinant activated factor VII(NovoSeven®/ rFVIIa) in Massive PPHIntroduction:1. Recombinant Activated factor VII (NovoSeven®) is a natural initiator of coagulation cascade. It binds to tissue factor at the site of vascular injury which leads to formation of thrombin. rFVIIa activates factor X on the surface of activated platelets at the site of vascular injury, resulting in a localized thrombin burst, leading to a rapid formation of stable fibrin clots at the site of vascular injury.2. rFVIIa is licensed for treatment of bleeding episodes and prevention of excessive bleeding in connection with surgery in patients with inherited or acquired haemophilia with inhibitors to coagulation factors VII or IX. Use of rFVIIa in obstetrics haemorrhage is considered as off-label use.3. This guideline is intended for use in all specialist hospitals in Sarawak namely Sibu, Miri, Bintulu, and Sarawak General Hospital. The guideline can be used for district hospitals with O&G specialist like Sri Aman, Kapit, and Limbang. However, referral of cases with massive PPH should be the recommended option in district hospitals with specialists, as it lacks other clinical services. 121Department of O&G, Sarawak General Hospital
  • 122. Indications:Consider rFVIIa use in salvageable patient with life-threatening massive postpartumhaemorrhage that fails to respond to appropriate surgical interventions and conventionalblood component therapy.Absolute contraindications:Known allergy to mouse, hamster or bovine proteinsAbsolute contraindications:Known allergy to mouse, hamster or bovine proteinsCURRENT AVAILABLE NOVO 7 VIALS:(The old dosage of 1,200 mcg per vial may no longer be available) 1. 1,000 mcg vial 2. 2,000 mcg vialDOSAGE OF NOVO 7 REQUIRED: 1. 60 to 120 mcg/Kg – rounded up to the next whole vial 2. Based on the average maternal weight of 70kg and a dose of 90 mcg/Kg: 2.1 Using the 1000 mcg/vial: approximately 6 vials would be required 2.2 Using the 2000 mcg/vial: approximately 3 vials would be requiredHospitals with specialists in Sarawak: SGH, Miri, Bintulu, Sibu, Kapit, Limbangand Sri Aman hospitals should stock a minimum of 2 vials of the 2,000 mcg/vial and2 vials of the 1,000 mcg/vial. To allow flexibility in dosing based on weight. 122Department of O&G, Sarawak General Hospital
  • 123. Algorithm for use of rFVIIa (adapted from Malaysia Society of Haematology, Jan 2010) Massive Haemorrhage  Control of bleeding source with uterotonic agents, intrauterine balloons,BleedingStopped surgery (e.g. hysterectomy, B-Lynch brace suture and/or internal iliac artery ligation)or embolisation where available/possible  Blood components therapy (FFP: 15ml/kg; 4-6 units for 70 kg patient, Platelet: 1-2 units/10kg; 10-15 units for 70 kg patient, Cryoprecipitate: 1-2 units/10kg; 10-15 units for 70 kg patient)  Reversal of anticoagulation Persistent bleeding & generalized oozing despite surgical control and blood component therapy  Consider rFVIIa  Discuss with State Obstetrician (Dr Harris N.S.)  Attempt to correct (before giving rFVIIa): o Hct > 24% o Fibrinogen > 0.5-1.0 g/L (where available) o Platelets > 50 x 109/L o pH ≥ 7.2 Administer rFVIIa (Single bolus over 3-5 mins- dose 60-120 mcg/kg, rounded up to the next whole vial. One vial of Novoseven® = 1000 mcg, e.g. 6 vials for a 70kg woman and using the 2000 mcg/vial dose then 3 vials are needed ) Bleeding Stopped Consider after 30-60 minutes Persistent bleeding & generalized oozing- consider hysterectomy/ internal iliac artery ligation if not performed yet  Attempt to correct: o Hct > 24% o Fibrinogen > 0.5-1.0 g/L o Platelets > 50 x 109/L o pH ≥ 7.2 Re-adminster rFVIIa - dose 100 mcg/kg  Patients with massive PPH should be managed in HDU/ICU (massive PPH should be referred to specialist hospitals) 123 Department of O&G, Sarawak General Hospital
  • 124. 1.5.14 UTERINE INVERSION__________________________________________________________________________________There are 3 degrees of uterine inversion: 1. First degree: the fundus turning itself inside out but does not herniated through level of internal os. This degree is likely to be missed. 2. Second degree: the fundus passes through the cervix and lies within the vagina. This is the commonest type. 3. Third degree: the entire uterus is turned inside out and hangs outside the vulva. This is uncommon.TREATMENTThe best person to treat uterine inversion is those who attended to the delivery but a seniorperson should be informed at once.In the Hospital1. Immediate replacement should be performed without attempting to remove the placenta from the inverted uterus. The placenta can be dealt with later. i2. The indications to remove the placenta first are: 2.1 When it is necessary to reduce the bulk of the inverted mass in order to get through the narrowing cervical ring. 2.2 When almost all the placenta is already separated.3. In most instances the inversion occurs in the absence of skilled attendant and thus when first seen by the experienced personnel, patient is too shocked for replacement procedures.4. If it is a 3rd degree inversion, convert it to 2nd degree by raising the foot of the bed to maintain the inverted mass within the vagina instead of leaving it hanging outside.5. Give 1M Morphine l0 mg and set up IV drip with plasma or normal saline.6. GXM blood. 124Department of O&G, Sarawak General Hospital
  • 125. Replacement of the Uterus:1 A fairly deep anaesthetic or strong sedation should be given before attempting any manipulation.2. Manual replacement, 2.1 The part of the uterus which has inverted last should be replaced first, ie. the part nearest the cervix, and not the inverted uterine fundus. 2.2 The other hand should be over the abdomen to apply counter support. If this replacement is successful, give Ergometrine with the hand still within the cavity of uterus until the uterus contracts.3. Hydrostatic method of OSullivan 3.1 A double nozzle is passed towards the posterior fornix. The douche is raised to about 1 meter above level of vagina. 3.2 An assistant approximates the labia around his forearm so as to block the vulva. 3.3 A warm solution e. NS, distilled water is run into the vagina. The fluid distends the vaginal wall widening the cervix while a uniform pressure is exerted on the inverted uterus.4. Give IV Ergometrine 0.5mg and it is advisable to maintain the contraction with oxytocin infusion 40-80 units in NS, at 10-20 dpm.5. Cover with antibiotics.6. Operative manipulation is resorted to in long standing cases or when the above procedures failed. This can be done vaginally or abdominally.In Domiciliary Service1. Set up IV drip with NS and keep the patient warm with blankets2. The vulva is covered with sterile pad.3. Transfer patient to the nearest hospital, initiate Red Alert.4. Do not give Ergometrine or Oxytocin. 125Department of O&G, Sarawak General Hospital
  • 126. STAGES OF UTERINE INVERSION: Stage 1 Stage 2 Stage 3 126Department of O&G, Sarawak General Hospital
  • 127. MANUAL REPLACEMENT OF THE UTERUS:  REPLACE BY PUSHING THE PART THAT INVERTED LAST  SYSTEMATICALLY & GENTLY PUSH IN THE INVERTED UTERUS  ONCE COMPLETELY REPLACED KEEP HAND IN UTERUS UNTIL ERGOMETRINE OR OXYTOCIN INFUSION HAS PRODUCED A FIRM CONTRACTION 127Department of O&G, Sarawak General Hospital
  • 128. O‟SULLIVAN‟S HYDROSTATIC PRESSURE METHOD  Performed in OT under GA  Tube passed into the posterior fornix  Assistant close vulva around operator‟s wrist  Warm saline run in until pressure gradually restores position of uterus  Once replaced then start on oxytocin infusionSURGICAL METHOD OF REPLACEMENT OF INVERTEDUTERUS  Performed in OT by specialist/consultant  Stretch the constricting ring  Posterior part of the ring divided  Hook up the fundus  Once successful, start oxytocin infusion to contract the uterus  Repair the uterus  Look out for PPH  Brace sutures maybe necessary if uterus remained lax 128Department of O&G, Sarawak General Hospital
  • 129. 1.5.15 CORD PROLAPSE________________________________________________Cord prolapsed is an obstetric emergency. Early diagnosis and appropriate, timely actioncan save the baby. Often seen when the presenting part is not well applied to the lowersegment of the uterus.Cord Prolapsed is often diagnosed in:1. Malpresentation2. Preterm labour3. Multiparity4 Polyhydraminos5. Multiple gestation6. SROM (spontaneous rupture of membranes)7. Long cord8. Following amniotomy Management1. Initiate RED ALERT.2. Confirm viability of fetus (absence of pulsation in prolapsed cord is unreliable).3. Arrange for immediate delivery (cervical OS <8 cm for LSCS, OS >8 cm may attempt for instrumental delivery / ventouse extraction after discussing with specialist).4. Place patient in Sims position or genu-pectoral position - raised buttock on pillows.5. Maintain fingers within vagina to support the presenting part (thus avoiding compression of the cord).6. Replace exposed cord within the vagina and not to push the cord away (manipulation of cord will cause vasospasm).This may be achieved by using a sanitary pad soaked in warm water, which may be applied to the vulva.7. The maternal urinary bladder maybe distended with 500ml of sterile saline via a Foleys catheter.8. Oxygen therapy masks (4-6 L/min).9. Initiate intravenous infusion of tocolytics (in the absence of contraindications) to reduce established uterine contraction) eg: SC or IM Bricanyl 250microgram. *Always rule out cord prolapse in all cases of spontaneous rupture of membranes. 129Department of O&G, Sarawak General Hospital
  • 130. 2.5.16 SHOULDER DYSTOCIA DRILL–“ HELPER"______________________________________________________H Call for HELP: initiate RED ALERT!  Patient in lithotomy position, legs in stirrup with buttocks at edge of bed. Empty catheterise the bladder.E Perform / extend episiotomy  To create more space for greater access to the pelvis.L Legs - McRoberts Manoeuvre  hyperflex hips and knees, abduct and outward rotation of the hips  encourage maternal pushing  lateral neck traction / downward axial traction on the fetusP Pressure - apply suprapubic pressure to dislodge the anterior shoulder from  symphysis by pushing it into oblique diameter:  Stand on platform on the same side of fetal spine  Lateral suprapubic pressure  use the flats of assistants hands  apply behind anterior shoulder  continuous pressure  If unsuccessful after 30 sec, use rocking motionE Enter pelvis for internal rotation of shoulders Anterior shoulder:  hand into posterior aspect of vagina  moving it up to posterior aspect of anterior shoulder  push anterior shoulder from behind into oblique position Posterior shoulder: Corkscrew Maneuver  push posterior aspect of posterior shoulder through 180°, with change of hand at 90°.R Removal of posterior arm.  Use right hand if baby facing maternal left  Enter posterior aspect of vagina  Retrieve posterior hand or forearm  Sweep across the chest and face  Deliver the posterior arm 130Department of O&G, Sarawak General Hospital
  • 131. 3.0 APPENDICES3.1 Hydralazine infusion regime3.2 Labetolol infusion regime3.3 Magnesium Sulphate therapy3.4 Diazepam infusion regime3.5 Oxytocin augmentation / induction regime3.6 Nifedipine regime for tocolysis3.7 Salbutamol regime3.8 Heparin infusion regime3.9 Red Alert3.10 Indications for Pediatric referral3.11 Indications for Caesarean Section3.12 Guidelines for dating USS3.13 Sarawak PPH Box3.14 PPH management checklist3.15 Pictogram for estimation of blood loss3.16 Algorithm for the use of recombinant Factor 7 for PPH3.17 Guidelines on the management of low lying placenta in district hospitals of Sarawak3.18 Interpretation of CTG3.19 Obstetric guidelines for district hospitals without O&G specialist in Sarawak 131Department of O&G, Sarawak General Hospital
  • 132. 3.1 HYDRALLAZINE INFUSION REGIME 3. NEPRESSOL1 ampoule = 25mg/2mlRapid Control 4. Dilute 1 ampoule of nepressol with 8 ml of water, so 1ml = 2.5mg. 5. Give 2ml/ 5mg slow bolus. 6. Can repeat every 20 minutes up to a maximum of 2 doses, if DBP ≥ 110mmHg, to start infusion.Maintenance c. Via infusion syringe pump 4. Nepressol 50mg (2 amp = 4ml) + 46ml Normal saline = 1ml/1mg 5. Start at 1ml/hour (1mg/hour) 6. Increase every 20 minutes by 1 ml up to a maximum of 10ml/hour d. Via IV drip infusion 4. Nepressol 50mg (2 amp =4ml) + 500ml Normal saline = 10ml/1mg 5. Start at 15ml/hour (1.5mg/hour) 6. Increase every 20 minutes by 10 ml up to a maximum of 100ml/hour 4. APRESOLINE1 ampoule = 20 mgRapid Control 4. Dilute 1 ampoule with 8 ml of water, so 1ml = 2mg. 5. Give 2.5ml/ 5mg slow bolus. 6. Can repeat every 20 minutes up to a maximum of 2 doses, if DBP ≥ 110mmHg, to start infusion.Maintenance c. Via infusion syringe pump 4. Apressol 50mg (2 1/2amp = 5ml) + 45ml Normal saline = 1ml/1mg 5. Start at 1ml/hour (1mg/hour) 6. Increase every 20 minutes by 1 ml up to a maximum of 10ml/hour d. Via IV drip infusion 4. Apressol 50mg (2 1/2 amp =5ml) + 500ml Normal saline = 10ml/1mg 5. Start at 15ml/hour (1.5mg/hour) 6. Increase every 20 minutes by 10 ml up to a maximum of 100ml/hour 132Department of O&G, Sarawak General Hospital
  • 133. 3.2 LABETOLOL INFUSION REGIME1 ampoule = 25mg/5mlRapid Control 3. Give 1 ampoule slow bolus. 4. Can repeat every 20 minutes up to a maximum of 2 doses, if DBP ≥ 110mmHg, to start infusion.Maintenance c. Via infusion syringe pump 4. 50mg (2 amp = 10ml) + 40ml Normal saline = 1ml/1mg 5. Start at 20ml/hour (20mg/hour) 6. Increase every 30 minutes by 20 ml up to a maximum of 160ml/hour d. Via IV drip infusion 4. 200mg (8 amp =40ml) + 160ml Normal saline = 1ml/1mg 5. Start at 20ml/hour (20mg/hour) 6. Increase every 30 minutes by 20 ml up to a maximum of 160ml/hourContraindications to Labetolol: 4. Bronchial asthma 5. Congestive heart failure (CCF) 6. AV heart block 133Department of O&G, Sarawak General Hospital
  • 134. 3.3 MAGNESIUM SULPHATE THERAPY  1 ampoule = 2.47gm/5mlLOADING DOSEIntravenous  4gm (8ml) MgSO4 + 12ml Normal Saline or H2O given over 15 minutes  Further convulsion after 15 minutes:  2gm (4ml) + 8ml Normal Saline given over 15 minutesIntramuscular  10gm with 5gm (10ml) given at each buttockMAINTENANCE DOSEIntravenous  24.7gm (10 ampoules) + 500ml Normal Saline to run at 21ml/hr = 1gm/hrIntramuscular  5gm (10ml) deep IM in alternate buttock every 4 hours  *maintenance dose to continue up till 24 hours post-delivery or 24 hours from the last convulsion (whichever occurs later)ANTIDOTE FOR MGSO4 TOXICITY  1gm Calcium gluconate (10ml of 10% solution) given slow intravenous bolus over 3 minutes. 134Department of O&G, Sarawak General Hospital
  • 135. 3.4 DIAZEPAM (VALIUM) INFUSION REGIME  1 ampoule = 10mg/2ml (5mg/ml)RAPID CONTROL  IV Diazepam l0mg over 1-2 minutes.MAINTENANCE: effective dose 5-10mg/hr, maximum 3mg/kg/24hr VIA INFUSIONSYRINGE PUMP  50mg (10ml) in a syringe (5mg/ml) Start at 1 ml/hr (5mg/hr) Increase every 15 minutes by 0.5ml/hr Maximum 2ml/hr (l0mg/hr)MAINTENANCE: VIA INFUSION DRIP SET  40mg (8ml) Diazepam + 500ml 5% Dextrose (0.08mg/ml)  Start at l0 dpm (2.4mg/hr)  Increase every 15 minutes by l0dpm  Maximum 40dpm (9.6mg/hr) 135Department of O&G, Sarawak General Hospital
  • 136. 3.5 OXYTOCIN AUGMENTATION / INDUCTION REGIMEAim : To achieve good contraction, ie. 3 contractions in 10 minutes, each lasting up to 45 seconds.Dilution : 10 units (1ml) Oxytocin + 500ml Normal SalinePreparation : 1 ampuole = 10 units /1mlRegime : 1. To use either infusion syringe pump or IV drip infusion set (dropmat), using standard dilution. 2. Start at 2miu/min. 3. Increase every 30 minutes. 4. Maximum 32miu/min (32dpm or 96ml/hr). [20miu/min= recommended maximum dose by manufacturer] 5. 12 miu/min usually establishes adequate contractions.* Note: 1 ml = 20 drops, 1 dpm = 3 ml/hr DOUBLING REGIMEDOSE DROPMAT INFUSION SYRINGE PUMP2 miu/min 2 dpm 6 ml/hr4 miu/min 4 dpm 12 ml/hr8 miu/min 8 dpm 24 ml/hr16 miu/min 16 dpm 48 ml/hr32 miu/min 32 dpm 96 ml/hr INCREMENTAL REGIMEDOSE DROPMAT INFUSION SYRINGE PUMP2 miu/min 2 dpm 6 ml/hr4 miu/min 4 dpm 12 ml/hr6 miu/min 6 dpm 18 ml/hr8 miu/min 8 dpm 24 ml/hrlO miu/min 10 dpm 30 ml/hrI2 miu/min 12 dpm 36 ml/hr 136Department of O&G, Sarawak General Hospital
  • 137. 3..6 NIFEDIPINE REGIME FOR TOCOLYSISNIFEDIPINE SUPRESSIONLoading dose  T.Nifedipine 15 mg stat then 15 mg every 15 minutes for 4 dosesMaintenance dose  T.Nifedipine 20 mg tds for 48 hoursMonitoring of patient on Nifedipine suppression  Continuous monitoring of the fetal heart rate is recommended as long as the patient has contractions  Blood pressure and pulse every 15 mins for the first hour, then every 30 mins for the 2nd hour then hourly in the first 24 hours.Side effects of nifedipine  Tachycardia  Palpitations  Flushing  Headaches  Dizziness  NauseaHypotension is minimal if patient is normotensiveContraindication to Nifedipine suppression 1) Allergy to nifedipine 2) Hypotension 3) Hepatic dysfunction 4) Concurrent use of beta-mimetics, transdermal nitrates or other antihypertensive medication 137Department of O&G, Sarawak General Hospital
  • 138. 3.7 SALBUTAMOL SULFATE (VENTOLIN) REGIME  1 ampule = 0.5 mg/1 ml  Dilute according to table below  Increasing at 15 minutes interval  Maximun 45 μg/min  Preferably to use infusion syringe pump instead of dropmat to avoid volume overload.Note: 1 ml = 20 drops, 1 dpm = 3 ml/hrDosage in 45μg/min Infusion syringe pump Dropmat 5 mg (10 ampule) + 40 ml Dextrose 5 mg + 500 ml Dextrose 5% or 5% or Normal Saline Normal Saline dpm dpm ml/hr ml/hr5 μg/min 1 dpm 10 dpm 30 ml/hr 3 ml/hr10 μg/min 2 dpm 20 dpm 60 ml/hr 6 ml/hr15 μg/min 3 dpm 30 dpm 90 ml/hr 9 ml/hr20 μg/min 4 dpm 40 dpm 120 ml/hr 12 ml/hr25 μg/min 5 dpm 50 dpm 150 ml/hr 15 ml/hr30 μg/min 6 dpm 60 dpm 180 ml/hr 18 ml/hr35 μg/min 7 dpm 70dpm 210 ml/hr 21 ml/hr40 μg/min 8 dpm 80 dpm 240 ml/hr 24 ml/hr45 μg/min 9 dpm 90 dpm 270 ml/hr 27 ml/hr 138Department of O&G, Sarawak General Hospital
  • 139. 3.8 HEPARIN INFUSION REGIME & MONITORING Bolus : 5000IU Infusion : Start at 1000 IU/hr (24000 IU/day) Dilute : 25000 IU Heparin in 50 ml 5% Dextrose or Normal Saline (500 IU/ml) Infusion Rate (ml/hr) Dose (iu/hr) 1.5 750 2.0 1000 2.5 1250 3.0 1500 3.5 1750 4.0 2000 Monitoring: Target APTT is 60 - 85 SECONDS Check APTT 6 HOURS after bolus, and there after follow as in the table 139Department of O&G, Sarawak General Hospital
  • 140. APTT Instruction Rate changes Dose Recheck Changes APTT (ml/hr) (iu/hr) <50 Give bolus 5000u +0.3 +150 6 hours later 50-59 +0.2 +100 6 hours later 60-85 0 0 Next AM 86-95 -0.1 -50 Next AM 96-120 Hold 30 minutes -0.2 -100 6 hours later >120 Hold 30 minutes -0.3 -150 6 hours later 140Department of O&G, Sarawak General Hospital
  • 141. 3.9 RED ALERTTeam members 1) OBGYN Team: 2) Anaesthetic Team: 3) Paramedic Team: 4) Other members: as requiredFlow ChartOn-call OBGYN ConsultantOn-call OBGYN SpecialistOn-call OBGYN Medical Officer - FIRST CALLOn-call OBGYN Medical Officer - SECOND CALLOn-call AnaesthetistOn-call Anaesthetic Medical Officer - MO OT CALLDuring officer hour: LR Sister After office hour: Sister On CallAny additional members to be decided by Team Leader at the scene.Indications: 1) PPH 2) Severe APH 3) Eclampsia 4) Severe Cardiac Condition 5) Obstetric Collapse Decision by Medical Officer / House Officer for RED ALERT INITIATE for RED ALERT by: LR Staff Nurse / House Officer Operator to inform the respective team member indicating the PLACE clearly Patient attended by RED ALERT TEAM RED ALERT call off after appropriate management Members of the ‘Red Alert’ or ‘Code Red’ team may differ in non specialist hospitals. It should include putting the ambulance service on standby to reduce delays in transferring patients to specialist hospitals. 141Department of O&G, Sarawak General Hospital
  • 142. 3.10 INDICATIONS FOR REFERRAL TO PEDIATRICMEDICAL OFFICER1. Prematurity <36 weeks.2. Birth weight < 1.7kg3. Fetal distress4. All babies with congenital anomalies5. Maternal risk of sepsis in babies, eg: 5.1 Fever of >38°C 5.2 UTI and on antibiotics 5.3 Foul smelling liquor 5.4 PROM or PPROM >.24 hours6. Mothers with bad obstetric history7. Instrumental delivery8. All meconium stained liquor babies other than light meconium stained liquor.9. Grunting / flat babies10. Babies with 5 minute APGAR score of <7/1011. Babies whose mother has: 11.1 Chicken pox 11.2 Herpes simplex type II and undergone vaginal delivery 11.3 PTB (if untreated / sputum +ve) 11.4 HBsAg or HBeAG+ve ./ *- 12. Rhesus negative mothers 13. Infant of diabetic (or impaired GTT) mother. 14. All babies >4kg. 142Department of O&G, Sarawak General Hospital
  • 143. 3.11 INDICATIONS FOR CAESAREAN SECTIONMaternal Factors1. Maternal request, eg: a) Mature primigravida b) History of subfertility c) Refusal trial of scar2. Previous poor obstetric outcome / bad obstetric history3. Maternal disease, eg: a)Cardiac disease b)Malignancy c)Respiratory disease d)Infections, eg i. HIV ii. Active genital herpes infections4. Contracted pelvis / CPDPregnancy Factors1. Impending eclampsia2. Eclampsia3. Diabetic mellitus - poorly controlled4. Peripartum cardiomyopathyUterus / Placenta / Umbilical Cord Factors1. Previous caesarean section, eg: a) Previous one caesarean section - failed trial of scar b) Two previous caesarean sections c) Three or more previous Caesarean sections d) Previous classical Caesarean section2. Scar dehiscence3. Scar rupture4. Uterine rupture5. Previous myomectomy x6. Previous severe cervical tear7. Pelvic tumour, eg: a) Obstructing the birth passage b) Cervical fibroid or lower segment fibroid8. Uterine anomalies: a) Tough vaginal septum9. APH a) Abruption placenta a) Placenta praevia (with or without haemorrhage)10. Cord prolapse11. Infection of placenta / uterus a) Chorioamnionitis 143Department of O&G, Sarawak General Hospital
  • 144. Fetal Factors1. Multiple pregnancy a) Twin - lsl twin non vertex b) Monochorionic monoamniotic twin c) Twin with other risk factor eg. previous scar, PIH, cardiac disease, etc. d) Retained second twin (O63.2) e) Triplet or more2. Mal presentation (O32) a) Breech b) Transverse c) Oblique lie d) Face e) Brow f) Compound g) Cord presentation h) Unstable lie3. Suspected / presumed fetal distress (non-reassuring fetal status) including:-(O68) a) Meconium stained liqour b) CTG anomaly4. 1UGR5. MacrosomiaLabour Process Factor1. Long labour a) Prolonged 1st stage / poor progress (O63.0) b) Prolonged 2nd stage (O63.1) c) Retained 2nd twin (O63.2)2. Failed induction of labour (O61)3. Failed trial of scar4. Failed instrumental deliver} (O66.5) a) Ventouse b) Forceps c) Ventouse & forceps "Coding as in ICD 10.” 144Department of O&G, Sarawak General Hospital
  • 145. 3.12 GUIDELINES FOR DATING USSCalculating Gestation Age (GA) on the basis of menstrual history is often risky. Manywomen are uncertain of their dates, and even when the menstrual history is known to becorrect, individual variation in the time of ovulation can alter the length of a cycle from25-35 days.  All pregnant mothers should have early (<20 weeks) dating ultrasound if there is no resources problem.  Early dating ultrasound must be done for patients who are : o Unsure of date o Having irregular menses o On Hormonal contraception up to 3 months before pregnant o No menses since last childbirth  The first structure that can be measured for the purpose of dating is the Gestational Sac (GS) o Usually early, less than 6 weeks o Should only be used before the appearance of the embryo o Use Mean Sac Diameter (MSD). o Most reliable up to 14 mm MSD ( Generally accepted up to 25mm MSD) o Be careful not to be mistaken with pseudosac (in ectopic pregnancy). o Accuracy +/- 5 days. o Repeat scan after 10-14 days to establish viability.  Crown Rump Length (CRL) o Once embryo is seen, CRL should be measured. o Can be used up to 14 weeks (CRL 84 mm). o Be careful not to include Yolk Sac (YS) in the measurement. o Measure pole to pole if fetus not well formed. o True mid sagittal view in well formed fetus. o Accuracy +/- 5 days. o No need repeat scan to confirm date. o Between 12-14 weeks, if there is a difficulty in obtaining true mid sagittal plane, then a composite measurement of FL-BPD or FL-HC can be used (accuracy +/- 7 days) 145Department of O&G, Sarawak General Hospital
  • 146.  14-20 weeks, FL, BPD, HC o From 14 weeks onward Femur Length (FL) and Biparietal Diameter (BPD) or Head Circumference (HC) should be measured. o Use composite date based on FL-BPD or FL-HC o Accuracy +/- 10 days o If there is significant different between femur and head measurement, consider fetal anomaly (either skeletal or brain anomalies)  Deciding date o Up to 14 weeks :- Use LMP if USG date is within +/- 5 days of LMP date by GS or CRL measurement , otherwise revise the date following USG measurement o 12-14 weeks (If using FL-BPD/FL-HC):- Use LMP date if USG date is within +/- 7 days of LMP date, otherwise revise the date following USG measurement o 14-20 weeks:- Used LMP if USG date is within +/- 10 days of LMP date, otherwise revise the date following USG measurement. o Do not change the earlier date.  Dating after 20 weeks (Uncomplicated pregnancy) o USG date is used as a reference (FL-BPD/FL-HC) o Take AC measurement as well o If AFI is normal, and AC correspond to FL-BPD/FL-HC repeat growth scan in 2 weeks time. o If subsequent 2 weekly scan (2x) is normal , no need further scan until 38 weeks ( scan still indicated for usual obstetrics indication in between) o Repeat AFI at 40 weeks o Consider IOL if at 40 weeks is abnormal (low). 146Department of O&G, Sarawak General Hospital
  • 147. 3.13 SARAWAK PPH BOX Inventory checklist(Please ensure all items are replenished after used)ITEM QuantityIV Cannula size 14, 16, 18 gauge 3 of each sizeIV drip set 3 unitsMicropore/ Plaster to secure cannula 3 rollsGelafundine 500ml 1 pintNormal saline 500ml 2 pintsOxytocin 10 iu/ml 10 ampoulesSyntometrine 2 ampoulesCarboprost/ Haemabate 250 mcg/ml 4 ampoules kept in the fridgeWater for injection 10ml 5 ampoulesSterile vaginal pack 3 packsSyringe 5ml, 10ml 3 of each sizeHypodermic Needle 21 (green), 23(blue) gauge 3 of each sizeBakri Balloon with manual 1 unitFoley catheter size 24F 2 unitsUrine bag 1 unit 147Department of O&G, Sarawak General Hospital
  • 148. 3.14 PPH MANAGEMENT CHECKLIST Hospital/Clinic: _______________________ Date: __________________________ Patient‟s name: ___________________________ Age: __________________________ IC No: ____________________________ Time of call for help: ________ AM / PM Called by: _______________ Team Member Name Time arrivedInitial Management Time On-call O&G SpecialistOxygen given On-call MO On-call Anaesthetic MOHead bed down On-call AnaesthetistBrannula No. 1Brannula No. 2Brannula No. 3 Observations Fluids/blood/blood products Time Pulse BP Type Volume Time Blood sent Time FBC GXM units PT/PTT Placenta delivered Yes No Urinary catheter Drug Dose Time Syntometrine IM 1 ampule Ergometrine IM/IV 500mcg/ 1 amp (if normal BP) Oxytocin 40 units in 500ml N/S at 125ml/H Haemabate (Carboprost) IM 250 mcg/ 1amp Haemabate (Carboprost) IM 250 mcg/ 1amp Haemabate (Carboprost) IM 250 mcg/ 1amp Haemabate (Carboprost) IM 250 mcg/ 1amp Haemabate (Carboprost) IM 250 mcg/ 1amp Haemabate (Carboprost) IM 250 mcg/ 1amp Haemabate (Carboprost) IM 250 mcg/ 1amp Haemabate (Carboprost) IM 250 mcg/ 1amp Name O&G specialist called: ________________________ Time: ________ AM / PM (If from non-specialist hospital) Form filled by: Signature: “PPH management Check List” should be filled for every case of PPH” 148 Department of O&G, Sarawak General Hospital
  • 149. 3.15 PICTOGRAM FOR ESTIMATION OF BLOOD LOSS Quarter soaked – 20mls Half soaked – 50mls Sanitary pads Fully soaked – 100mls Quarter filled – 100mls Half filled – 250mls Completely filled kidney dish – 500mls 500mls Kidney Dish 149Department of O&G, Sarawak General Hospital
  • 150. Quarter soaked linen protector– 500mls Half soaked linen protector – 1000mls Almost fully soaked – 1500mls Half soaked sarong – 400mls Fully soaked sarong – 700mls Fully soaked vaginal pack – 80mls 150Department of O&G, Sarawak General Hospital
  • 151. 3.16 ALGORITHM FOR USE OF RECOMBINANT FACTOR 7 FOR MASSIVE PPH Algorithm for use of rFVIIa (adapted from Malaysia Society of Haematology, Jan 2010) Massive Haemorrhage  Control of bleeding source with uterotonic agents, intrauterine balloons,BleedingStopped surgery (e.g. hysterectomy, B-Lynch brace suture and/or internal iliac artery ligation)or embolisation where available/possible  Blood components therapy (FFP: 15ml/kg; 4-6 units for 70 kg patient, Platelet: 1-2 units/10kg; 10-15 units for 70 kg patient, Cryoprecipitate: 1-2 units/10kg; 10-15 units for 70 kg patient)  Reversal of anticoagulation Persistent bleeding & generalized oozing despite surgical control and blood component therapy  Consider rFVIIa  Discuss with State Obstetrician (Dr Harris N.S.)  Attempt to correct (before giving rFVIIa): o Hct > 24% o Fibrinogen > 0.5-1.0 g/L (where available) o Platelets > 50 x 109/L o pH ≥ 7.2 Administer rFVIIa (Single bolus over 3-5 mins- dose 60-120 mcg/kg, rounded up to the next whole vial. One vial of Novoseven® = 1000 mcg, e.g. 4-7 vials for a 70kg woman and using the 2000 mcg/vial would require 2 to 3 vials ) Bleeding Stopped Consider after 30-60 minutes Persistent bleeding & generalized oozing- consider hysterectomy/ internal iliac artery ligation if not performed yet  Attempt to correct: o Hct > 24% o Fibrinogen > 0.5-1.0 g/L o Platelets > 50 x 109/L o pH ≥ 7.2 Re-adminster rFVIIa - dose 100 mcg/kg  Patients with massive PPH should be managed in HDU/ICU (massive PPH should be referred to specialist hospitals)  Combination of 2 of the 2000 mcg/vial and 2 of the 1000 mcg/vial should be made available in hospitals with O&G specialists 151 Department of O&G, Sarawak General Hospital
  • 152. 3.17 GUIDELINES ON THE MANAGEMENT OF LOW LYING PLACENTA IN SARAWAK DISTRICT HOSPITALS______________________________________________________________________________Maternal and fetal morbidity and mortality from placenta praevia are considerable and areassociated with high demands on health resources. With the rising incidence of caesarean sectionoperations combined with increasing maternal age, the numbers of cases of placenta praevia andits complications will continue to increase.Transvaginal ultrasound is safe in the presence of placenta praevia and is more accuratethan transabdominal ultrasound in locating the placenta.In the second trimester, 26–60% of cases of low-lying placenta diagnosed by TAS are reclassifiedby TVS, while in the third trimester TVS changed the TAS diagnosis of placenta praevia in up to12.5%.Placenta Praevia SGH settingGestation Finding Action21-23 weeks Placenta overlaps the OS Rescan at 36 weeks36 WEEKS (No Placental edge < 2cms from Admit and book for elective LSCS 38history of the internal OS weeks. Group and save biweeklybleeding)APH – one Admit for observation. Biweekly group andepisode at any save. Repeat scan at 34-36 weeks to recheckgestation placenta edge using TVS Specialist to decide if considering discharge. Must fulfil following criteria:  Ambulance coverage (within 10km)  Own transport within 30 minutes  Adult who can drive, staying with patient at all times  Appropriately counselledAntenatal managementWomen with major placenta praevia who have previously bled should be admitted and managedas inpatients. Those with major placenta praevia who remain asymptomatic, having never bled,require careful counseling and specialist input before contemplating outpatient care. Any home-based care requires close proximity with the hospital, the constant presence of a companion andfull informed consent from the woman. (RCOG guideline) 152Department of O&G, Sarawak General Hospital
  • 153. Placenta Praevia in District Hospital settings: (1) Incidental finding of Placenta Praevia (No bleeding ) Major Minor MCH outpatient monitoring (if ‹ 32 weeks › 32 weeks no bleeding) and rescan at 36 gestation weeks Outpatient Admit to District monitoring by hospital If they do not fulfil the criteria MCH doctor for OPD monitoring, to be unless they are admitted to district hospital living in inaccessible area › Rescan at 36 weeks 1 hour journey from hospital If still PP, admit to specialist hospital till delivery(2) Antepartum Haemorrhage (Placenta Praevia) District Hospital Major Minor  Admit to district Hospital Admit to district Hospital and manage accordingly (refer to  Stabilize patient then transfer specialist for opinion) to Specialist Hospital after consulting O&G specialist on call 153Department of O&G, Sarawak General Hospital
  • 154. Definitions:Minor – Placenta at the lower segment of uterus but not reaching the os (Type 1 & 2 )Major – Placenta reaching and covering the OS (Type 3 & 4 and Type 2 posterior)(Transvaginal probe is preferred for accurate diagnosis but in the absence of TVS,transabdominal scan with full bladder)Guideline for Outpatient monitoring of placenta praevia in District Hospital - Hb ≥ 10g/dl ( prescribe iron supplement or transfusion if necessary ) - Staying within 1 hour of hospital ( by transport ) - Transport available to bring patient to hospital - Carer lives with patient - Patient understand and accept risk involved with outpatient management - Patient couselled to seek help as soon as possible when started to bleed - Advised to avoid sexual intercourse/using vaginal tamponReference 1. Routine ultrasound screening in pregnancy: Protocol, standards and training. Report of the RCOG working party, July 2000, RCOG Press. 2. Bhide A, Prefumo F, Moore J, Hollis B, Thilaganathan B. Placental edge to internal os distance in the late third trimester and mode of delivery in placenta praevia. BJOG. 2003; 110(9): 860-4. 154Department of O&G, Sarawak General Hospital
  • 155. 3.18 INTERPRETATION OF CTG REACTIVE TRACE:  Normal baseline heart rate, variability, presence of acceleration (2 in 20 minutes trace) and absence of deceleration BRADYCARDIA:  A baseline FHR persistently low than 110 bpm  Cord compression /prolapsed  Congenital heart malformation  Drugs  Late fetal hypoxia  unknown TACHYCARDIA:  Persistent baseline > 160 bpm  Maternal pyrexia  Fetal infection  Chronic hypoxia  Hyperthyroidism or maternal stress  Fetal hormones in response to stress  Gestational age < 32 w  Drugs  Excessive fetal movements 155Department of O&G, Sarawak General Hospital
  • 156. POOR BASELINE VARIABILITY:  Baseline variability < 5bpm  Fetal hypoxia  Fetal sleeping pattern  Maternal sedation  Gestational age <28-30 weeks  Congenital malformation SINUSOIDAL PATTERN:  A smooth, wave like baseline, absent beat to beat variability  Causes :  Severe hypoxia  Anaemic fetus  idiopathic FETAL TACHYCARDIA WITH POOR BASELINE VARIABILITY  Moderate to severe hypoxia  Analgesia with pethidine 156Department of O&G, Sarawak General Hospital
  • 157. EARLY DECELERATIONS  Onset of decelerations is at the onset of contractions  Likely due to fetal head compression  Not associated with fetal hypoxia LATE DECELERATIONS  Deceleration occur more than 15 seconds after the peak of contraction  Reduction in placental blood flow (abruption, hyperstimulation)  Maternal related disease (PIH)  Fetal compromised (IUGR, premature)  Supine hypotension VARIABLE DECELERATIONS  Umbilical cord entanglement  Cord round neck  True knot  Cord prolapsed 157Department of O&G, Sarawak General Hospital
  • 158. PROLONGED DECELERATIONS  A consistent drop in fetal heart rate > 30 bpm, lasting 2 minutes  Total umbilical cord occlusion  Uterine hypertonic  Maternal hypotension  Cord compression SUDDEN PROLONGED BRADYCARDIA  If OS is full and patient is pushing – cord around neck?  Severe hypoxia  Always correlate CTG changes with clinical findings 158Department of O&G, Sarawak General Hospital
  • 159. 3.19 OBSTETRIC GUIDELINES FOR DISTRICT HOSPITALS WITHOUT O&G SPECIALIST IN SARAWAK____________________________________________________________ A. NEW GUIDELINES ON PIH/PE  Daily low dose aspirin 75mg (1/4 tab of 300mg tablets) to be given to antenatal mothers from 12 weeks onwards till 36 weeks or till delivery if they have one or more of the following risk factors:  Timing Hypertensive disease in previous pregnancies  Chronic renal disease  Autoimmune disease like SLE, anti-phospholipid syndrome  Type 1 or 2 diabetes  Chronic hypertension  Timing of delivery for antenatal mothers with PE is by 37 weeks POA  Timing for delivery for antenatal mothers with PIH on anti-hypertensive is by 38-39 weeks POA (depending on cervical favourability)  Timing of delivery for PIH not on anti-hypertensives by 40 weeks POA  Patients with severe PIH/PE should be given IM 5GM of Magnesium Sulphate in each buttock before transfer to a hospital  Patient should have 1 or 2 functioning IV line before transfer  A syringe filled with 2GM of Magnesium Sulphate should be prepared and labelled and brought along in the ambulance to be given IV slow bolus over 5 minutes if the patient had an episode of eclampsia in transit  A 10mg ampoule of diazepam (valium) should also be made available in the ambulance. It can be prepared in the ambulance and given by slow bolus IV over 5 minutes, if the repeated IV slow bolus of 2MG magneseium sulphate does not abort the eclampsia.  In the absence of IV line, the above can be given IM  Where available per rectal 10mg diazepam is an acceptable alternative to IV diazepam in cases where an IV line is not available B. ANTENATAL & POSTNATAL MOTHERS ATTENDING OPD/A&E  Recurring incidences of maternal deaths in the state occuring from poorly managed antenatal & postnatal mothers attending OPD/A&E is very worrying  All such patients MUST be reviewed by a Medical Officer and in specialist hospitals by an O&G Medical Officer  All such patients must be treated as „HIGH RISK CASES‟  Low tolerance to admitting patients for further monitoring & management (particularly if from far)  Risk of DVT & pulmonary embolism is significant in unwell mothers, particularly those that have poor appetite and does not ambulate well.  Infectious diseases also poses a significant risk during pregnancy and in the postnatal period and should be treated appropriately  High risk mothers from remote areas or who lives far away from the nearest hospital should be advised to reside near a hospital or preferably in specialist hospitals by 36 weeks. 159Department of O&G, Sarawak General Hospital
  • 160. C. GENERAL ADVICE TO REDUCE RISK OF DVT / PULMONARY EMBOLISM  Complete Rest in Bed (CRIB) is generally not recommended  Antenatal & postnatal inpatients are advised to ambulate and move their lower limbs regularly to reduce risk of DVT  Patients with known history of DVT or at high risk of VTE should be managed accordingly after consultation with an O&G specialist  All postpartum patients should be counseled about DVT/VTE risk by the MO or the nursing staff upon discharge:  Drink sufficient water (approx. 6 glasses per day)  Encourage ambulation  To seek treatment early if feeling unwell, not ambulating or unable to tolerate orally  All postnatal patients are at risk of DVT/VTE, medical staff doing home visiting or upon seeing postnatal mothers in clinics/A&E/OPD should be aware of such risk.  Postnatal patients in the pueperal period must be asked, “ARE YOU FEELING WELL?”, “ARE YOU DRINKING ENOUGH WATER?”, “ARE YOU ABLE TO MOVE AROUND?” and they should be advised to seek medical care as soon as possible whenever, they are unwell or unable to drink or ambulate. D. GRANDMULTIPARAS  Should be „strongly‟ advised to deliver in specialist hospitals  Over 60% of maternal mortality in Malaysia are grandmultiparas  Grandmultips presenting in labour in non specialist hospitals must be reviewed and managed by a MO. Cases should be referred to an O&G specialist and managed as advised.  MO should review the patient during the immediate post partum period . E. INDUCTION OF LABOUR  Induction for post date should be performed at 40 weeks plus 7 days in non specialist hospital setting. This is due to the prevalence of „unsure of dates‟ and lack of dating scan in the district, thus the policy to induce these patients slightly earlier than in specialist hospitals is preferred.  Induction for any other indication than for „post date‟ should be discussed with the O&G specialist on call/ „buddy‟ specialist  Only 1 prostaglandin E2 should be inserted per day and only 2 prostin insertions are allowed. Approval for the 3rd prostin should be obtained from the „buddy‟ specialist or the O&G specialist on-call.  Monitoring should be performed as follows:  CTG should be done and „reactive‟ before the insertion of prostaglandin  CTG should be repeated about 1 hour post insertion  MO must attend immidiately if uterine hyperstimulation is diagnosed 160Department of O&G, Sarawak General Hospital
  • 161.  At least 2 hourly „timed contractions‟ when contracting  CTG should be repeated 4 hourly as long as the patient continues to contract (*pls take note of the rate of uterine contractions)  Where CTG is not available, other methods of fetal heart monitoring is acceptable.  MO must review & sign on all abnormal CTG trace F. INDUCTION FOR „SOCIAL‟ INDICATIONS:  The department of O&G as a principle do not recommend induction or elective LSCS for trivial/social reasons such as, „looking for a good date‟.  However, induction for social reasons may be beneficial for a high risk antenatal patient (grandmultip, elderly, h/o PPH, retained placenta) if the patients stays in remote areas and/or may have difficulty getting a hospital for delivery.  Clinicians managing antenatal patiens with such a profile should consider earlier delivery at about 37 weeks POA  Docotrs managing any high risk patients (PIH, GDM, twins, etc) who are at risk of not being able to deliver in hospital due to very low socio-economic status, staying in remote areas or have transportation difficulties, should consider admitting the patient in the hospital at about 36 weeks or earlier depending on circumstances and consider an earlier IOL for social reasons.  Home deliveries or even clinic deliveries in high risk patients may result in maternal morbidity or mortality. G. „TRIAL OF SCAR‟  Ideally, should be carried out only in specialist hospitals  Patients with previous scar should be counseled by the attending Medical Officer (MO) at 32-36 weeks POA about „mode of delivery‟  Patients who prefers a „trial of scar‟ and are not contraindicted, should be advised to go to the nearest specialist hospital when in early labour and not wait till they are in advanced labour  Patients who presented to the non specialist hospital in labour should be transferred to the nearest specialist hospital if possible  If patient arrives in advanced labour, consult the O&G specialist on call and manage as advised  If patient refuse to be transferred, consult O&G specialist for advice. H. LSCS WITH A PREVIOUS LSCS SCAR  All elective LSCS with a previous scar should be performed in specialist hospitals or district hospitals with O&G specialist. Obtain an appointment date by 34 weeks.  Emergency LSCS with a previous scar, please consult the O&G specialist on call for advice. Decision should be based on: 161Department of O&G, Sarawak General Hospital
  • 162.  Expertise availibility  Indications for LSCS  Distance from specialist hospital  Availibility of transport I. GENERAL ADVICE FOR LSCS IN THE DISTRICT HOSPITAL  MO who lacks experience to perform LSCS should be assisted by a colleague who is more experienced  Relatively more difficult LSCS (ie. LSCS at full dilatation or after failed instrumental delivery) should be performed by the more experienced MO in the district  MO should seek assistance from their colleagues early when facing difficulties during an LSCS.  Unless contraindicated, all patients who had LSCS in the district hospitals should be given thromboprophylaxis 6 hours after the procedure for 7 days or until the patient is discharged.  Subcutaneous low molecular weight heparin (e.g. clexane 40mg OD or tinzaparin 0.45mls OD for women between 50Kg to 90Kg)  Subcut. heparin 5000 IU BD  Dose may differ depending on patient‟s weight  If considered as „High Risk‟ (refer to VTE guide) then the postnatal mothers should be given 7 days of LMWH even after discharge  All post LSCS patient should be encouraged to ambulate early or exercise their lower limbs regularly to reduce the risk of DVT or venous thromboembolism (VTE)  Patients who at high risk of DVT or Pulmonary Embolism should be given the full 7 days of thromboprophylaxis J. INSTRUMENTAL DELIVERIES  Forcep delivery is discouraged unless the MO is experienced or has been privileged & credentialed to perform the procedure.  Ventouse delivery is allowed providing the MO is able to perform the procedure and all the prerequisites/criteria are fulfilled  If the on-call MO has no experience, please obtain the assistance of a colleague who can perform the procedure.  After office hours, the MO should ensure that LSCS can be arranged quickly should the attempted ventouse fail. The OT staff on call would have to be informed and transport to pick them put on standby. K. TWIN & BREECH VAGINAL DELIVERIES  Both type of deliveries should not be conducted in district hospitals  ECV should be recommended for breech presentations at 36 weeks onwards, providing the patient is not in labour and there are no contraindications 162Department of O&G, Sarawak General Hospital
  • 163.  The patient can be referred to a specialist hospital for ECV. Kindly consult O&G specialist or MO on-call for appointment.  MO in non specialist hospital should not attempt ECV unless has been priviledged & credentialed to perform it.  In cases of twin pregnancy or breech presentation presenting to district hospitals in advanced labour, please consult O&G specialist for advice  All must be started on 40 units pitocin/500mls NS, to run over 4 to 6 hours soon after delivery after the routine bolus dose of uterotonics  All grandmultips must be closely monitored at 30 minute intervals for at least 4 hours in the post delivery period, preferably in the Labour Ward or in the acute bay of the Maternity/Female ward. L. GENERAL RULES TO FOLLOW FOR LABOUR MANAGEMENT  All abnormal CTG trace must be reviewed and signed by the MO on call or MO on duty  If CTG is not available, regular fetal heart monitoring must be performed and recorded on the case note or appropriate charts  In the second stage of labour when CTG trace are usually difficult to interprete, fetal heart monitoring after each contractions should be noted and recorded  Active phase of labour starts at 4cm cervical dilatation  All patients in the active phase of labour or those who had ARM following IOL should be started on the Partogram  Non high risk pregnancies in labour should be reviewed at least 4 hourly and if there is a delay in progress, the MO on duty should be informed and review the patient  MO on duty must be informed & attend stat all cases of hyperstimulation (contractions > 5 in 10 minutes), „fetal distress‟, shoulder dystocia, massive APH/PPH or other obstetric emergencies M. „CODE RED‟ – RESPONSE TO O&G EMERGENCIES CALL SYSTEM TO BE IMPLEMENTED IN ALL HOSPITALS  The CODE RED call system should be activated for obstetric emergencies like major obstetric haemorrhage, eclampsia, cord prolapse and when a patient collapses  Each hospital should identify the staffs who should be called by the operator/staff and what would be an acceptable response time  In a typical non specialist district hospital, the MO on-call, NS of LW or senior nurse in-charge must be called at the same time. If surgery maybe required then the MO must ask the operator/staff to call the OT staff/lab staff to come in.  On activation of Code Red in district hospitals, ambulance driver and ambulance should be on standby for possible transfer. This would reduce the time taken to transfer patient or to perform surgery or to obtain blood. 163Department of O&G, Sarawak General Hospital
  • 164. N. MANANAGEMENT OF MASSIVE PPH  LW staff and Medical Officers have to organize drills to familiarize themselves with the acute management of massive PPH  PPH Box to be available in all Labour Wards  PPH Quick Guide is made avilable and should be in PPH box  Prevention is the best policy!  All mothers at high risk of PPH (grandmultip, previous h/o PPH &APH, polyhydramnios & multiple pregnancies) should have their blood cross- matched if presenting to district hospitals/clinics in labour  All high risk patients should have 40 units pitocin/500ml N/S for 4 hours after delivery – compulsory!  Diagnose early, respond quickly and manage appropriately....REFER EARLY!  IM carboprost (haemabate) will be made available in all hospitals shortly. Follow PPH quick guide on use of Carboprost.  Use Bakri balloons as per guideline, once inserted refer to specialist hospital  Obtaining blood as quickly as possible is crucial in managing PPH. Blood should be sent along with patient when she is transferred to a specialist hospital  Refer to PPH management chart O. GOOD PRACTICE WHEN REFERRING ILL OBSTETRIC PATIENTS TO SPECIALIST HOSPITALS  Generally, the time taken between the decision to transfer and arrival in specialist hospital is longer than expected with transport being the main issue. Appropriate planning of getting the driver and transport to be on standby is important in ensuring the transit time is kept to a minimum.  Optimize patient before transfer, having at least one IV line should be compulsory  Ensure a medical staff (preferably a MO) escorts the patient. If the MO is unable to escort because there are no other doctors in the hospital/clinic, inform the specialist and get a staff nurse or AMO to escort.  In cases of APH or PPH, bring available blood along  The ambulance should be equipped with resuscitative equipment  The ambulance should be equipped with a non invasive digital BP monitor P. DUTIES OF THE HOSPITAL DIRECTORS  Hospital directors to ensure regular drills for obstetric emergencies should be carried out at least 6 monthly in all district hospitals  Hospital directors to ensure regular annual updates on current obstetric management for doctors & nurses managing maternity patients are carried out  Hospital directors to ensure regular „audits‟ of poor clinical outcomes are carried out regularly as stipulated in the recent „State Health Conference‟ in Miri. 164Department of O&G, Sarawak General Hospital
  • 165.  Hospital directors to ensure the above guidelines are implemented and practiced. Hard copy of this guideline must be made available in LW & Female ward for easy reference.  Hospital directors should attend State CEMD meetings if a maternal death that occurred in his/her hospital is being discussed. Q. GENERAL ADVICE  Consultation & discussion of any difficult O&G cases with the assigned „buddy‟ specialists or O&G specialist on-call are encouraged  Consultations with the „buddy‟ specialists only within office hours  Kindly post this Obstetric Guidelines on the notice board in LW for easy quick referencePrepared by:Dr. Harris N Suharjono FRCOGConsultant & HeadDepartment of O&G, Sarawak General Hospital(State O&G Consultant)1.2.2012 165Department of O&G, Sarawak General Hospital
  • 166. 4.0 CONTACT NUMBERS 4.1 Consultants & Specialists & Medical Officers:No: Name: Mobile Number:1. Dr. Haris Njoo Suharjono 012-88854502. Dr. Rafaie Amin 012-88917323. Dr. Sim Wee Wee 016-88917704. Dr. Nicholas Ngeh 016-87008995. Dr. Edawati Dahrawi Edrus 013-98389666. Dr. Sukanda Jaili 017-89900587. Dr. Tan Yiap Loong 012-21232998. Dr. Lim Soon Hock 017-22887909. Dr. Muniswaran Ganeshan 012-587122010. Dr. Nurulhuda Shamsudin 013-802327211. Dr. WaiKokYau 012-468201812. Dr. Roland Harris 019-828048013. Assoc. Prof. Dr. Awie Ak Idi 013-816890214. Assoc. prof. Soe Lwin 016-859589415. Dr. John Lim 012-380893716. Dr. Jessie 012-675157017. Dr. Jenny Kiu 016-8664999 18. Dr. Maslina 013-8238302 19. Dr. Tan Lee Na 019-8885231 20. Matron Mariam 019-8489418 21. Matron Quence Sakai 019-8482216 22. 23. 24. 25. 166Department of O&G, Sarawak General Hospital
  • 167. 4.2 Telephone Extensions:No: Place: Extensions:1. O&G Office 10312. O&G HOD Office 10293. O&G HOD Fax 082-2766804. Hospital Directors Office 10115. Labour Ward -Triage 44046. Labour Ward - Nurses Counter 40127. Maternity 1 3028 /30298. Maternity 2 5045 / 50299. Gynaecology Ward 2407 / 240910. Main OT 3942 / 5954 / 593911. O&G Specialist Clinic 5051 167Department of O&G, Sarawak General Hospital