SALSO Series - Safe Deliveries in District Hospitals

1. Safe Deliveries In District
Hospitals
- An Overview about the Management
of Common Cases in the District
Setting -
By : Dr. S. Sentilnathan

2. MAP OF MALAYSIA
Perlis
Thailand
Kedah
Pulau
Kelantan
Pinang Perak
Terengganu
Peninsular Malaysia
Malaysia
Selangor Land area: 330,252 km2 Sabah
Pahang
Population: 26.6 million
Wilayah Persekutuan
Kuala Lumpur Negeri
Sembilan
Melaka
Johor
Sarawak
Singapura
Sarawak
Land area: 124,499 km2
Population: 2.3 million

4. Kuching Call Miri Call Limbang
Hospital
Centre Centre
Bintulu
Hospital Lawas
Daro
Lundu Hospital
Hospital
Hospital
Mukah
Hospital
Marudi
Simunjan Hospital
Hospital
Sibu Hospital
Kapit
Hospital
Kanowit
Hospital
Sarikei
Hospital
Bau
Hospital
RCBM Hospital Sri Aman Betong Saratok
Hospital Hospital
Hospital
Sentosa Hospital
Serian
Hospital

5. HEALTH FACILITIES IN SARAWAK LAWAS
LIMBANG
Keys :
Hospita/Urban OPD
MIRI
Klinik Kesihatan MARUDI
Klinik Desa
MCHC
VHT by river
VHT by road
BINTULU
VHP
FDS Bases
MUKAH
FDS Locations
DARO
BELAGA
SIBU
KANOWIT
SARIKEI
KAPIT
LUNDU
SARATOK
KUCHING
BAU
BETONG
KOTA SAMARAHAN
SERIAN
SIMUNJAN SRI AMAN
KALIMANTAN
KALIMANTAN

6. Flying Doctor Service
Ba Kelalan Clinic, awas District
Batu Lintang Clinic, Sri Aman
Village Health Teams
Sarawak General Hospital, Kuching
Kapit Polyclinic, Kapit
Miri Hospital, Miri

7. CASES COMMONLY SEEN IN DISTRICTS :
1. Pre-Eclampsia / Eclampsia
2. Breech Presentation
3. Post Partum Hemorrhage
4. Previous Scar
5. Cord Prolapse
6. Antepartum Hemorrhage
7. Multiple Pregnancy
8. Big baby
9. PPROM
10. IOL

8. PIH / Pre-Eclampsia / Eclampsia
Relevant Hx
Baseline Ix
BP > 160/110 – start antihypertensives
Freq of f/up : once a mth till 28/52
once in 2/52 upto 34/52
once a week till delivery
USG – once a mth before 28/52
once every 2/52 after 28/52
Criteria for referral to ANSC :
protenuria >/= +1
req more than 1 antihypertensive
abnormal baseline ix
suspected IUGR
Prev h/o Severe PE/ Eclampsia/ IUGR

9. Criteria for Immediate Referral to Hospital :
BP > 160/110 x2 with rest in btw
BP > 180/110 or MAP > 125
Refer Specialist – start MgSO4 (if >1hr start)
T.Nifedipine 10mg stat
IV line
Transfer to nearest hospital with escort and IV Diazepam
Monitor vitals n signs of mg toxicity during transfer
All pt with protenuria 2+ or more
All pt with Sx of IE
Eclampsia
IM MgSO4 5g each buttock
IV Diazepam 10mg slow bolus
rpt 15mins later if still fitting
inform specialist n transfer pt once stable asap
**MgSO4 is to be used for Eclampsia only in districts. Can use for Severe PE/
IE after consulting specialist on call. Pt req MgSO4 has to be transferred to
specialist hosp asap with escort, resusc equipment and close monitoring.

10. Eclampsia : Call for HELP !
A, B, C
Left lateral
Oropharyngeal airway, O2
Reg. suction
2 large bore IV Line
IM MgSO4 / IV Diazepam
Refer Specialist
Arrange fr transfer
Ensure pt Stable
If distance by road > 2hrs –
Other faster means of
transport.
resusc equipment
O2, V/S, FHR
IV Diazepam standby

11. Post Partum Hemorrhage
CALL FOR HELP !
Attend stat ! NO Over The Phone Management
A, B, C
2 large bore IV line – take baseline ix and start fluid resusc
Close V/S Monitoring
Quick assessment of blood loss and cause
Check Placenta and Membranes / genital tract trauma
Retain Bits of Placenta - MRP
Cervical tear – walk in cervix
- if present, try to suture. If unable to suture, pack vagina
/ clamp the tear site, stabilise pt and transfer with escort.

12. Uterine Atony – massage uterus
start iv pit 40u
ensure synto / im oxytocin given at del of ant shoulder
2nd dose can be given 15mins later provided to htn/hd
no hemabate in districts, thus continue 10u pit every
15mins
Inform specialist
stabilise pt – adequate fluid resusc / blood tx
methods to buy time
(eg : during transfer or awaiting OT)
condom + cathether and NS (int tamponade)
Bimanual compression
Abd Aorta Compression
Vaginal Packing