POCKET BOOK

GUIDELINES & PROTOCOLS FOR

COMMON OBSTETRIC EMERGENCIES &
CLINICAL CONDITIONS
for
Doctors and Midwives

Swaziland EmONC Services

January 2016
Table of Contents
CHAPTER 1: MANAGEMENT OF LABOUR (pregnancy, childbirth, postpartum
and newborn care) 7
CHAPTER 2: ELECTRONIC FETAL HEART RATE (FHR) MONITORING 11
CHAPTER 3. PRETERM LABOUR 14
CHAPTER 4: INDUCTION OF LABOUR 18
CHAPTER 5: PREVENTION AND MANAGEMENT OF 22
POST-TERM PREGNANCY 22
CHAPTER 6: PREMATURE RUPTURE OF MEMBRANES 25
CHAPTER 7: MANAGEMENT OF PATIENT WITH PREVIOUS CAESAREAN
SECTION (VBAC) 28
CHAPTER 8: MANAGEMENT OF 31
PROLONGED LABOUR and OBSTRUCTED LABOUR 31
CHAPTER 9: OBSTRUCTED LABOUR 34
CHAPTER 10: ANTEPARTUM HAEMORRHAGE 36
CHAPTER 11: POST-PARTUM HAEMORRHAGE (PPH) 41
CHAPTER 12: SEVERE PRE-ECLAMPSIA/ECLAMPSIA 44
CHAPTER 13: FLUID MANAGEMENT IN CRITICALLY ILL PATIENT 49
CHAPTER 14: MANAGEMENT OF ANAEMIA IN PREGNANCY 52
CHAPTER 15:THE MANAGEMENT OF MISCARRIAGE 54
CHAPTER16: PUERPERAL SEPSIS 58
CHAPTER 17: MANAGEMENT OF SEVERE SEPSIS AND SEPTIC SHOCK 60
ANNEXES: ALGORITHMS FOR SELECTED CLINICAL CONDITIONS. 65

2
3
Preface
This pocket book was developed to create uniformity in the management of
obstetric emergencies and other clinical conditions. The pocket book was
conceived out of the need to standardise patient care throughout the Kingdom of
Swaziland and to facilitate mentorship of staff in facilities.

The conditions addressed in this pocket book were identified as the most
frequent causes of maternal and neonatal mortality and morbidity during the
quarterly maternal and neonatal death reviews. The pocket book covers
important topics like obstetric haemorrhage, obstetric sepsis, management of
labour (maternal and foetal monitoring), prematurity and post maturity, and
induction of labour.

This pocket will serve as a valuable companion in the day-to-day management of

patients in labour and as a reference during maternal death reviews (MDR) at
facility and regional level.

These Guidelines and Protocols were derived from various documents, which
include the SES document, RCOG and WHO guidelines.

The Reproductive and Sexual Health Unit is proud to present the pocket book to
all the facilities in the country.

4
Acknowledgement
The Pocket book is a product of obstetricians and gynaecologists, doctors, and
midwives from various facilities in Swaziland and from the Sexual Reproductive
Health unit. The SRH unit wishes to thank all facility managers who released
their staff to participate in the production of these Guidelines and Protocols.
Special appreciation goes the colleagues who developed the initial drafts on
which the team worked from for final development of the protocols. Sincere
gratitude goes to all the colleagues who endured long sessions of discussions to
come up with these fairly user friendly Guidelines and Protocols.

Finally we wish to thank the World Bank and WHO and the Ministry of Health for
providing the resources needed for the development of these Guidelines and
Protocols.

5
Foreword
The Ministry of Health is delighted to present this Pocket Book of Guidelines and
Protocols for common obstetric emergencies and clinical conditions for doctors
and midwives in the Kingdom of Swaziland. The Pocket Book comprises
comprehensive Guidelines and Protocols on important emergencies and clinical
conditions, which contribute to the high maternal and neonatal mortality and
morbidity in the Kingdom. It is a response to recommendations made during
maternal death reviews conducted in the past in the country. The pocket book
will set standards to be used during Maternal Death reviews at the health
facilities, regional, and national levels.
Adherence to these standards will have a positive impact in the reduction of
maternal and neonatal mortality in the country. It will serve as an essential tool
in ensuring that pregnant women, the foetus and the neonate can access quality
care during pregnancy, childbirth and the postpartum period. These standard
operation procedures operationalise the guidelines in the SES document to
practical day-to-day interventions required for patient care.
There has been stagnation in the reduction of maternal and neonatal mortality in
the Kingdom over the last two decades. These Guidelines and Protocols will
equip staff in facilities to respond appropriately to obstetric and neonatal
emergencies. Emergency Obstetric and Neonatal Care is an essential service that
facilitates management of the adverse events of pregnancy and childbirth at all
levels of care in order to save lives of mothers and their babies.
The Pocket Book is a result of major collaborative efforts and wide consultative
processes with specialists, doctors and midwives involved in the provision of
maternal and neonatal care service in the Kingdom of Swaziland. These
Guidelines and Protocols will assist health worker as well as managers to review
their current working practices in relation to current evidence based practices.
They will ensure a readily available source of information to everyone providing
care to mother and neonates. There will be periodic review and expansion in
response to needs identified in the maternal, perinatal and neonatal death
reviews, which have been established in all regions.
Finally, I wish to commend and congratulate SRH Program under the leadership
of the deputy director public health for its commitment in spearheading this
process to completion and the World Bank for providing technical and financial
support and to all the health facilities that released their staff to participate in
the development of these Guidelines and Protocols.
All health workers across the country are encouraged to use it.

Dr S.V Magagula
Director of Health Services, Ministry of Health Swaziland

6
Abbreviations used in this pocket book
ABC Airway, breathing, circulation
ACOG American College of Obstetricians and Gynaecologists
ALI Acute lung injury
ANC Antenatal clinic
APH Antepartum haemorrhage
ARDS Acute respiratory distress syndrome
BMI Body mass index
BP Blood pressure
BPM Beats per minute
C/S Caesarean section
cm Centimeter
CPD Cephalo-pelvic disproportion
CRP C – Reactive Protein
CTG Cardiotocograph
CVP Central venous pressure
CXR Chest X-Ray
DBP Diastolic blood pressure
DIC Disseminated intravascular coagulation
EFW Estimated fetal weight
EmONC Emergency obstetric and neonatal care
FBC Full blood count
FHS Foetal heart rate
HIV Human immunodeficiency virus
ICU Intensive care unit
IM Intramuscular
IU International units
IUGR Intra uterine growth retardation
IV Intravenous
IVI Intravenous infusion
Kg Kilogram
LMWH Low molecular weight heparin
LNMP Last normal menstrual period
MAP Mean arterial pressure
mcg Microgram
MgSO4 Magnesium Sulphate
N/S Normal saline
PCPNC Pregnancy, Childbirth, Postpartum and Newborn Care
PIH Pregnancy induced hypertension
PO Per os
PPH Postpartum haemorrhage
PPROM Preterm premature rupture of membranes
PROM Premature rupture of membranes
R/L Ringers lactate
RAM Rapid assessment and management
RCOG Royal college of Obstetricians and Gynaecologists
RVF Rectovaginal fistula
SIRS Systemic Inflammatory Response Syndrome
SRH Sexual and reproductive health
U&E Urea & electrolytes
UFH Unfractionated heparin
USG Ultrasonograph
VBAC Vagina birth after Caesarean Section
VVF Vesicovaginal fistula
WHO World Health Organization

CHAPTER 1: MANAGEMENT OF LABOUR (pregnancy,

childbirth, postpartum and newborn care)

7
OBJECTIVE: Ensure a safe outcome of pregnancy, perinatal periods ensuring a health
mother and neonate.

The majority of maternal and neonatal deaths occur during the perinatal (labour and
48 hours after delivery).

FIRST STAGE LABOUR

The first stage of labour has two phases: Latent and Active
Latent phase of labour is defined as the period when the cervix dilatation is between
0-3 cm and contractions are weak, less than 2 in 10 minutes.

The management should include

1. Take baseline of vital signs of the mother

2. A 20-minute baseline CTG. If CTG is abnormal follow guidelines on Electronic
Fetal Monitoring Guidelines and Protocols.
Parameters to monitor and record hourly the following:

● Frequency and intensity and duration of contractions.

● Foetal heart rate
● Mood and behaviour (distressed, anxious) of the mother.
● Record findings regularly in the Labour record and later in Partograph.
● Record time of rupture of membranes and colour of amniotic fluid.
● Give the woman supportive care.
● Never leave the woman alone.
Parameters to monitor every 4 hours:

● The cervical dilatation (unless otherwise indicated).

● Temperature
● Pulse
● Blood pressure.

a) After 8 hours if:

● Contractions are stronger and more frequent but

● No progress in cervical dilatation with or without membranes ruptured.
Refer woman urgently to hospital for further assessment if in the clinic.

b) After 8 hours if:

● No increase in contractions, and

● Membranes are not ruptured, and
● No progress in cervical dilatation.
Discharge the woman and advise her to return if:

8
 ● Pain/discomfort increases
● Vaginal bleeding occurs
● Membranes rupture.
c) If the cervical dilatation is 4 cm or more: -

● Begin plotting the Partograph and

● Manage the woman as in active Phase Labour, cervix 4 cm or more,
contractions 3 in 10 minutes, strong duration 40-50 seconds.
MANAGEMENT

Parameters to monitor Every 30 Minutes

● Take initial vital signs (RAM).

● Frequency, intensity and duration of contractions.
● Foetal heart rate.
● Mood and behaviour (distressed, anxious).
● Record findings regularly in the Labour record and Partograph.
● Record time of rupture of membranes and colour of amniotic fluid.
● Give supportive care.
● Never leave the woman alone.

Parameters to monitor every 4 hours

● Cervical dilatation - Unless otherwise indicated; do not do vaginal examination

more frequently than every 4 hours.
● Temperature.
● Pulse.
● Blood pressure.
● Assess progress of labour (contractions, dilatation, and descent).
● Dilatation should be at least one cm per hour.
SECOND STAGE OF LABOUR: When the cervix is dilated to 10 cm. This stage can last
up to 2 hours in primigravida.

Management: Deliver the baby and give immediate support

1. Parameters to monitor every 5 Minutes

● For emergency signs, using rapid assessment (RAM).

● Frequency, intensity and duration of contractions.
● Fetal heart rate.
● Perineum thinning and bulging.
● Visible descent of fetal head or during contraction.
● Mood and behaviour (distressed, anxious).
● Record findings regularly in Labour record and Partograph.
● Give Supportive care.

9
● Never leave the woman alone.
● Ensure all delivery equipment and supplies, including newborn resuscitation
equipment, are available, and place of delivery is clean and warm (25°C).
2. Deliver the baby, administer oxytocin, keep warm, clamp and cut cord 1-3 minutes
after delivery.

THIRD STAGE OF LABOUR:

● For emergency signs, using rapid assessment (RAM).

● Feel if uterus is well contracted.
● Mood and behaviour (distressed, anxious).
● Time since third stage began (time since birth).
● Record findings, treatments and procedures in Labour record and Partograph.
● Give Supportive care.
●Never leave the woman alone.

Deliver Placenta and ensure the following

● 10-IU Oxytocin IM is given.
● Await strong uterine contraction (2-3 minutes) and deliver placenta by controlled
cord traction
● The placenta and membranes are complete.
● The uterus is well contracted and there is no heavy bleeding.
● Repeat check every 5 minutes.
● The perineum, lower vagina and vulva are examined for tears.
● Collection, estimation and recording of blood loss throughout third stage and
immediately afterwards.
● Clean the woman and the area beneath her. Put sanitary pad or folded clean
cloth under her buttocks to collect blood. Help her to change clothes if
necessary.
● Keep the mother and baby in delivery room for a minimum of one hour after
delivery of placenta.
● Dispose of placenta in the correct, safe and culturally appropriate manner.
Parameters to monitor every 15minutes for the neonate

● Breathing: listen for grunting; look for chest in-drawing and fast breathing
● Warmth: check to see if feet are cold to touch.
FOURTH STAGE OF LABOUR

Parameters to monitor every 15 minutes in the first hour

Care of the mother and newborn within the first hour of delivery:

● Vital signs (pulse, BP, Respiration, Temperature)

● State of the uterus and Vaginal bleeding
Then monitor all parameters hourly for 3 hours.

Finally 4 hourly till patient is discharged.

10
● Do not discharge before 24 hours after delivery.
● Document /record findings, treatments and procedures in Labour record and
Partograph; Keep mother and baby in delivery room - do not separate them.
● Never leave the woman and newborn alone.

Ref: pregnancy, childbirth and postpartum period are extracted from the PCPNC 3 rd
Edition, 2014).

____________

The Ministry of Health SRH Unit coordinated the development of these

Guidelines and Protocols in January 2016.

CHAPTER 2: ELECTRONIC FETAL HEART RATE

(FHR) MONITORING
PURPOSE: To detect foetal distress at an early stage, either in the
antenatal period or intrapartum.

AIM: To allow attending midwife/doctor to intervene and/or deliver

baby before permanent damage is done.

RESULT: Reduce intrapartum asphyxia and stillbirths.

PARAMETERS:

The average FHR is 140 beats per minute (bpm) and is greater earlier in pregnancy
e.g.

Average FHR at 20 weeks = 155 bpm.

Average FHR at 30 weeks = 144 bpm.

BASELINE FHR

11
The baseline FHR is the rate (in bpm) at which the heart is set for most of a
10-Minutes’ period of monitoring.

Normal 120 – 160 bpm

Tachycardia Mild 160 – 180 bpm

Severe > 180 bpm

Bradycardia Mild 100 – 119 bpm

Severe < 100 bpm

The comprehensive interpretation of the CTG includes the following;

1. Baseline
2. Beat to beat variability
3. Accelerations
4. Decelerations

ANTEPARTUM FHR MONITORING

The following categories of patients will have Non-Stress Test (NST), when
admitted after 28 weeks gestation: -

▪ Suspected intra-uterine growth retardation (IUGR)

▪ Decreased foetal movements

▪ Postdates

▪ Maternal hypertension

▪ Maternal diabetes mellitus

▪ Bad obstetric history

▪ History of trauma to abdomen

▪ History of APH

The duration of monitoring should be at least 20 minutes.

NOTE: Foetal movements should be marked on the chart for correct interpretation
of the CTG.

INTRAPARTUM MONITORING

The following categories of patients will be on continuous foetal heart monitoring.

12
 1. Suspected intra-uterine growth retardation (IUGR)

2. Maternal diabetes

3. Maternal hypertension

4. Maternal febrile Illness

5. History of antepartum haemorrhage (APH)

6. Patients having Induction of labour

7. Patient on Oxytocin.

8. Trial of scar (VBAC -previous Caesarean Section, surgery to the uterus

such as myomectomy)

9. When there is meconium stained liquor

Except where the CTG is obviously normal the doctor on call MUST see and if in
doubt seek senior opinion (consult).

ACTIONS FOR ABNORMAL CTG IN LABOUR

Aim to improve foetal oxygenation, relieve acidosis and abolish the abnormal foetal
heart rate pattern.

1. Change maternal posture

2. Check blood pressure

3. Correct hypotension

4. Check maternal temperature and correct

5. Improve maternal oxygenation

6. Assess uterine activity, discontinue Oxytocin infusion

7. Do a vaginal examination to exclude cord prolapse and assess progress in

labour

13
 8. In the absence of Foetal Blood Sampling and there is no improvement in
the quality of the CTG, expedite delivery of the baby.

Routinely all women admitted to the labour ward should have a baseline CTG for a
minimum period of 20minutes.

The time of commencement and termination of monitoring should be entered in ink

on the tracing paper and signed by the attending health staff. The tracing paper
should be advanced to show clearly where the tracing of the fetal heart ended.

The midwife in charge will ensure availability of tracing paper in the Unit at all times.

____________

The Ministry of Health SRH Unit coordinated the development of these

Guidelines and Protocols in August 2015.

CHAPTER 3. PRETERM LABOUR

DEFINITION: Preterm labour is defined as labour occurring before 37 completed

weeks of pregnancy. Management depends on the gestational age and/or
estimated fetal weight (EFW). It is usually necessary to do an ultrasound scan to
assess fetal weight and normality.

GESTATIONAL AGE GREATER THAN OR EQUAL TO 34 WEEKS OR EFW

GREATER THAN OR EQUAL TO 2KG:

1) Aim to deliver patient as soon as possible.

2) Exclude specific causes of preterm labour e.g. chorioamnionitis or other
infections and abruption placenta and manage as appropriate.
3) Admit to labour ward.
4) Manage labour as for term pregnancies.
GESTATIONAL AGE 28-33 WEEKS OR EFW 1000-1999 G:

1) Admit to High care area for conservative management. If at health centre

give stat doses of dexamethasone and antibiotics before referral. If at
clinic, refer immediately to hospital.

14
 2) Give ampicillin 1g IV 6 hourly and metronidazole 400mg orally 8 hourly
(subject to availability of drug sensitivity report).
3) Give Dexamethasone 12 mg IM 12 hourly for 2 doses
4) Run a CTG tracing
5) If there is evidence of abruption placenta or chorioamnionitis, allow
labour to proceed under close fetal monitoring with CTG, or consider
caesarean section.
6) If the cervix is greater than or equal to 6cm dilated, allow labour to
proceed.
7) If the cervix is less than 6cm dilated, inhibit contraction by giving a
tocolytic such as Nifedipine or hexopranaline/salbutamol (see below)
8) Intravenous atosiban (Oxytocin receptor antagonist) may be available for
certain patients (e.g. cardiac disease).
9) If the above tocolytic agents fail to stop contractions, add indomethacin
100mg suppository, followed by another dose after 12 hours if necessary.
WHEN SHOULD TOCOLYTIC DRUGS BE USED?

Tocolysis should be considered if the few days gained would aid in

completing a course of corticosteroids or in utero transfer to centres with
neonatal services.

CONTRAINDICATIONS TO TOCOLYSIS

1) Lethal congenital or chromosomal malformation

2) Intrauterine infection (chorioamniotis)
3) Severe pre-eclampsia
4) Placenta Abruptio
5) Advanced cervical dilatation (Greater than or equal to 6cm)
6) Evidence of fetal compromise or placental insufficiency
NIFEDIPINE REGIMEN

1) IV line with Ringer-Lactate, run 500mls fast followed by 125ml/hour.

Give nifedipine 20mg orally, then 10mg after 30 minutes if painful
contractions persist. Follow with 10mg orally every 4 hours if there are
painful contractions, up to 48 hours (maximum dose 60mg/48hrs).Then
allow labour to proceed if contractions persist. Ensure close monitoring of
blood pressure.

HEXOPRENALINE AND SALBUTAMOL REGIMENS

1) Give hexopranaline 10 mcg IV over 5 minutes, then add 300 mcg to 1 litre
Normal Saline to run at 60 ml/hour. Increase by 10ml/hour every 30
minutes until contractions stop, or maternal heart rate reaches 120 beats
per minute or infusion rate reaches 120ml/hour

15
 OR
1) Give salbutamol 0.1-0.2 mg IV over 5 minutes, then add 10 mg to 1
litre Normal Saline, to run at 60 ml/hour. Increase by 10ml/hour
every 30 minutes until contractions stop, or maternal heart rate
reaches 120 beats per minute or infusion rate reaches 120 ml/hour.
2) Stop infusion after 24 hours and allow labour to proceed. Further oral
dosing is not required.

PRECAUTIONS:

● These agents should only be given in a high care area under close
monitoring and supervision.
● Do not give these agents to mothers with cardiac disease,
hyperthyroidism, uncontrolled diabetes mellitus or severe pre-eclampsia.
● Do not give these agents to women with a heart rate greater than or equal
to 120b/min.
● Give one agent at a time.
● Observe pulse ½ hourly or connect to a cardiac monitor.
● Measure blood pressure hourly.
● Auscultate the mother’s lungs every 2 hours to exclude pulmonary
oedema.
● Do not allow maternal heart rate to exceed 120b/min.

ATOSIBAN REGIMEN
● Give an initial dose of 6.75 mg IV over 1 minute, followed by an infusion of
18mg/hour for 3 hours, then 6 mg /hour up to 45 hours (maximum
330mg).

ANTENATAL STEROID THERAPY

INDICATION:

▪ Enhance production of surfactant for lungs of the premature foetus.

CONTRA-INDICATION:

● Overt systemic infection

USE WITH CAUTION:

▪ Diabetes
▪ Hypertensive Disease

16
In all other circumstances, steroids should be considered balancing potential
risks to the mother against proven advantage to the foetus.

Give steroids to any premature onset of labour between 25 and 35 weeks.

The decision to withhold steroids should be made at Consultant level.

REGIMEN:

▪ Betamethasone/Dexamethasone 12mg I.M.

2 doses 12 hourly interval

If in established labour, give Betamethasone/Dexamethasone 12mg I.M.

irrespective of cervical dilatation. Repeat after 12 hours if undelivered.

NB. Restrict fluid intake if the patient is receiving Beta-agonists (such as

Ritodrine) simultaneously with steroids. Incidences of acute pulmonary oedema
have been reported in these patients.

ALGORITHM FOR THE MANAGEMENT OF PRETERM LABOUR

Preterm labour

GA > 34 wks GA 28-33wk GA 26-27wks

Fetus>2000g Fetus Fetus <1000g

1000-1999g

Dexamethasone
Allow labour
to proceed Allow labour to
progress

Cervix >6cm Cervix < 6 cm and

No abruptio, No
OR chorioamnionitis
Placenta Abruptio and No fetal
distress
Chorioamnionitis

17
 Antibiotics
Dexamethasone
Dexamethasone
Tocolysis
Allow labour to progress (Nifedipine/IV
salbutamol)
Consider C/S(If
abruption) Antibiotics

___________

The Ministry of Health SRH Unit coordinated the development of these

Guidelines and Protocols in August 2015.

CHAPTER 4: INDUCTION OF LABOUR

AIM:

To standardize the management of the induction of labour

OUTCOME

In order to improve the outcome for mother and baby, these guidelines and
protocols will be adopted for use at hospitals and health centers where
caesarean section can be performed.

DEFINITION

Induction of labour is the initiation of the process of labor in a woman who has
no contractions and with intact membranes. However induction may include
women with ruptured membranes and have no contractions, technically this is
stimulation of labour.

INDICATIONS

● Post dates
● Pre-eclampsia
● Diabetes

18
 ● Social (at 39 weeks or above by a specialist)
● IUGR
● Intra-Uterine Foetal Death
● Premature rupture of membranes when there is an indication as per guideline.

CONTRAINDICATIONS TO INDUCTION OF LABOUR

● Above Para 3.
● Previous uterine scar.
● All other obstetric complications that are the same as contraindications to a
vaginal delivery, e.g., placenta praevia grade 2 posterior and above and
malpresentations.
● Big baby estimated fetal weight >4 kg.

● Induction of labour should be started at 06h00 or as early as possible in the

morning.

PRE-REQUISITE TO INDUCTION

● Confirm gestational age

● Assess Bishop Score
●
MODIFIED BISHOP SCORE

To access cervical favourability

Points 0 1 2 3

Cervical <1 1-2 2-4 >4

dilatation (cm)

Cervical length >4 2-4 1-2 <1

(cm)

Station -3 -2 -1/0 >0

Cervical Firm Average Soft -

consistency

Cervical Posterior Mid-position Anterior -

position

19
A score of 8 or more indicates that the induction will succeed. Lesser scores
mean that the woman is unlikely to go onto spontaneous labour at that time and
induction is likely to fail.

INDUCTION METHODS:

Medical Induction

1) Prepidil gel (dinoprostone Cervical Gel) dose 0.5mg.

● Reassess after 6 hours. If the dilatation is 4 cm, rupture the membranes (not
indicated in HIV patients) and do not repeat the gel.
● If there is no cervical response to the initial dose, repeat dosing may be
given. The recommended repeat dose is 0.5 mg with a dosing interval of 6
hours.
● The maximum recommended cumulative dose for a 24-hour period is 1.5 mg
(i.e., 3 doses at 6 hourly intervals).

Administration of Prepidil gel:

▪ To properly administer the product, the patient should be in a dorsal

position with the cervix visualized using a speculum.
▪ Using sterile technique, introduce the gel with the introducer/cannula into
the cervical canal just below the level of the internal os.
▪ Administer the contents of the syringe by gentle expulsion and then remove
the introducer/cannula. No attempt should be made to administer the small
amount of gel remaining in the introducer/cannula.
▪ Following administration of Prepidil gel, the patient should remain in the left
lateral position for at least 15–30 minutes to minimize leakage from the
cervical canal.
▪ If the cervical dilatation is obtained, the recommended interval before giving
intravenous oxytocin is 6 hours from the last dose.

2) Prostin tablet (Prostaglandin E2).

● One tablet (3 mg) to be inserted high into the posterior fornix.
● A second tablet may be inserted after six hours if labour is not established.
Maximum dose 6 mg (i.e. 2 doses at 6 hourly intervals) in 24 hours.

3) MISOPROSTOL

20
Misoprostol for Induction of labour can be given orally or vaginally

ORAL MISOPROSTOL REGIMEN

● Make the misoprostol solution. Dissolve 1 tablet of misoprostol (200mcg) in

200mls tap water (1mcg/ml). Shake well before each dose is given. Discard any
unused solution after 12 hours.
● Give oral misoprostol 2 hourly as follows:
a) For nulliparas: First 3 doses 20ml(20mcg), then 40 ml (40mcg) 2 hourly for
up to 24 hours.
b) For multiparas: First 3 doses 10ml (10mcg), next 3 doses 20 ml (20mcg), then
40 ml (40mcg) 2 hourly for up to 24 hours.

VAGINAL MISOPROSTOL REGIMEN

50mcg (1/4 tablet) misoprostol inserted in the posterior fornix 6 hourly,

maximum 4 doses

In selected cases surgical or mechanical induction may be used e.g.

Artificial rupture of membranes and Foleys catheter respectively.

MONITORING DURING INDUCTION OF LABOUR:

● Wherever induction of labour is performed, facilities should be available for fetal

heart rate and uterine contraction monitoring and should be able to do C/S, 24
hours a day.
● Before induction of labour is carried out a normal fetal heart rate pattern should
be confirmed using electronic fetal monitoring.
● When contractions begin, fetal well-being should be assessed with continuous
electronic fetal monitoring.
● Once the cardiotocogram is confirmed as normal, intermittent auscultation
(every 15 minutes) should be used unless there are clear indications for
continuous electronic fetal monitoring.
● Bishop score should be reassessed at 6 hours or earlier if indicated after vaginal
Prostin tablet or gel insertion.
● Once active labour is established (i.e., cervical dilation of 4cm and above and
good contractions at a rate of 3-4 in 10 minutes each lasting at least 40 seconds),
maternal and fetal monitoring should be carried out using a partograph as
described in intrapartum care.
FAILED INDUCTION:

21
Definition: Labour not starting after two cycles of treatment as described above
(i.e. labour not starting after 72 hrs of prescribed medications). Note: closely
monitor the maternal and fetal wellbeing

Action:

● Healthcare professionals should discuss this with the patient and provide
support. The patient’s condition and the pregnancy in general should be fully
reassessed, and fetal well-being should be assessed using electronic fetal
monitoring.
● The subsequent management options include:
o A further attempt to induce labour (the timing should depend on the clinical
situation and the patient’s wishes).
o Caesarean section.
____________

The Ministry of Health SRH Unit coordinated the development of these

Guidelines and Protocols in August 2015.
.

CHAPTER 5: PREVENTION AND MANAGEMENT OF

POST-TERM PREGNANCY

AIM

To standardize the prevention and management of post-term pregnancy.

OBJECTIVE

To improve the outcome for mother and baby, these guidelines and protocols
will be adopted for use at the health centres and hospitals.

ASSESSMENT AND DIAGNOSIS OF POST TERM PREGNANCY

DEFINITION

Post term (post maturity): A pregnancy that has extended to or beyond 42

weeks (294days) gestation (WHO definition).

● 10% of mothers deliver post term.

● When calculating the gestational age by dates, the days should be counted from the
1st day of the LNMP.

DIAGNOSIS

22
● Accurate pregnancy dating using the last normal menstrual period (LNMP).
● First trimester ultrasound should be offered ideally between 11 and 14 weeks, to all
women as it is a more accurate assessment of gestational age than LNMP.
● If there is a difference of greater than 5 days between gestational age determined by
the LNMP and the gestational age determined by the first trimester ultrasound, the
estimated date of delivery should be adjusted as per the first trimester ultrasound.
● If there is a difference of greater than 10 days between gestational age dated using
the LNMP and the gestational age determined by a second trimester ultrasound
performed between 16 and 20 weeks, the estimated date of delivery should be
adjusted as per the second trimester ultrasound.
● When there have been both first and second trimester ultrasounds, the gestational
age should be determined by the earliest ultrasound.

MANAGEMENT

● When a women presents at > 42 weeks, perform a biophysical profile: - this includes
CTG, Liquor volume, Foetal movements and tone to help determine the mode of
delivery.
● At 41 weeks, evaluation should be initiated for possible induction of labour. The
evaluation should include:
o Examination of the lie, position, size and number of the fetuses.
o The ripeness of the cervix using the Bishops score. A ripe cervix shows that a
uterus is ready for labour when it is soft, effaced, dilated and central on the
presenting part
o Note: If the score exceeds 8, the chance of a successful delivery after
induction is the same as that following a spontaneous onset of labour.

● Women should be offered induction between 41 and 42 weeks as the present

evidence reveals a decreased perinatal mortality without increase of Caesarian
section.
● When planning an induction, the doctor should:
o Discuss the procedure fully with the patient.
o Explain the method to be used, any side effects, and the sequelae if it
fails.
● The patient should give her informed consent to the procedure. It may be advisable
for this to be in writing; if it is not, a note should be made by the doctor in the
patient’s records and signed.

[For additional guidance on induction, see the separate Induction of Labour

Protocol.)

23
COMPLICATIONS OF POST TERM PREGNANCY

FETAL AND NEONATAL RISKS

● Still birth or neonatal death rate in these cases is estimated at 4-7 deaths/1000
births in post-term pregnancies, compared to a rate of 2-3 deaths in term
pregnancies.
● Post-term babies may be bigger than an average baby, i.e. > 4.0 kg.
● Oligohydramnios.
● Increased risk of meconium aspiration leading to breathing problems.
● Shoulder dystocia.

MATERNAL RISKS

● Increased risk of Cephalo-Pelvic Disproportion (CPD).

● Prolonged labour and trauma to birth canal.
● Increased risk of bleeding and infections.
● Increased risk of having Caesarian section.
● Increased psychological stress

MANAGEMENT:

● If there is no evidence of foetal compromise and favourable Bishop’s Score; induce

labour and monitor progress of labour and foetal wellbeing.
● Any detection of maternal or foetal distress, an early recourse to Caesarean section
is recommended.

____________

The Ministry of Health SRH Unit coordinated the development of these

Guidelines and Protocols in January 2016.

24
 CHAPTER 6: PREMATURE RUPTURE OF
MEMBRANES
AIM

To standardize the management of premature rupture of membranes

OUTCOME

In order to improve the outcome for mother and baby, these guidelines and
protocols will be adopted for use at all levels of health facilities.

DEFINITION

Premature rupture of membranes (PROM) is the drainage of amniotic fluid

through the cervical canal before the onset of uterine contractions.

PROM may be Pre-term (before 37 weeks of gestation) or at-Term (post 37

weeks of gestation).

GENERAL MANAGEMENT OF PRELABOUR RUPTURE OF MEMBRANES

● Verify the patient’s estimated due date; this will be needed to make decisions
about management of the patient’s care.
● Admit the patient.
● Vital signs: pulse, blood pressure and temperature 4 hourly.
● Do urine dipstick.
● Check Fetal Heart Rate 4 hourly.
● Perform cardiotocograph (CTG).
● DO NOT perform digital vaginal examination.

25
● Perform sterile speculum examination to confirm drainage of amniotic fluid
and to exclude other lesions on the cervix or obvious cord prolapse.
● If in doubt, use litmus paper—liquor is alkaline (paper turns blue) while
urine and vaginal discharge are acidic (paper turns pink).
● In addition, liquor dried on a slide and examined under a microscope will
show ferning.
● Perform ultrasound for amniotic fluid index, i.e. to determine the liquor
volume.
MANAGEMENT OF PRE-TERM PROM (PPROM)

(PPROM occurs in approximately 3% of pregnancies and leads to 1/3 of pre-term

births.)

● Manage as indicated above in the general management.

● Strict bed rest.
● If rupture is
o Before 24 weeks, observe vital signs initiate process of evacuation by
stimulation after counselling the mother and significant others about
the risks
o Before 34 weeks (24-33 weeks) administer steroids as follows:
✓ Intramuscular betamethasone 12 mg every 12 hours for 24hrs,
OR
✓ Intramuscular dexamethasone 8 mg every 8 hours for 24hrs.
● Women should be observed every 4-6 hours for signs of clinical
chorioamnionitis, e.g., fever, uterine tenderness, fetal tachycardia, foul
smelling liquor. (NB Steroids may mask signs of chorioamnionitis)
● Regularly inspect the sanitary pad for the amount, color and odour of the
amniotic fluid.
● Sonar at least twice a week
● A weekly high vaginal swab and at least a weekly maternal FBC should be
considered.
● Oral erythromycin (500mg PO 6 hourly) should be given for 10 days
following the diagnosis of PPROM from 26 weeks’ gestation if there is no
clinical evidence of chorioamnionitis or maternal sepsis. Erythromycin is
indicated as antibiotic prophylaxis only. Depending on clinical judgment, Oral
metronidazole (flagyl) 500mg bid for 7 days may be added.
● Women with clinical signs of chorioamnionitis should be started on a broad
spectrum intravenous antibiotics and delivery should be undertaken
immediately.
● Deliver the baby if:
o Any evidence of infection.
o Severe oligohydramnios.
o Signs of fetal distress.

26
● Induction should occur at 34 weeks or if Estimated Fetal weight (EFW) is ≥
2kg if the mother does not go into labour spontaneously.
MANAGEMENT OF PPROM > 34 WEEKS AND PROM >37 WEEKS

● Manage as indicated above in the general management.

● Confirm gestational age.
● Perform CTG.
● If no evidence of fetal distress, leave patient for up to 24 hours. (80% of
patients will go into labour within 24 hours with no further intervention.)
● If patient does not go into labour within 24 hours:
o And the cervix is unfavourable; ripen the cervix with prostaglandins as
per the Induction of Labour Standard Operating Procedure.
o Stimulate labour with oxytocin and deliver the baby.
o Vaginal delivery is preferable unless there is an indication for caesarean
section.
● Consider antibiotic prophylaxis where appropriate.
● Monitor labour normally.
NOTE:

1. Inform the paediatrician of all pre-term deliveries.

2. Where facilities for management of premature babies (less than 34 weeks)
are not available, transfer is preferable whilst baby is in utero. Tocolysis may
be considered in these patients if contractions occur.
____________
The Ministry of Health SRH Unit coordinated the development of these
Guidelines and Protocols in August 2015.

27
 CHAPTER 7: MANAGEMENT OF PATIENT WITH
PREVIOUS CAESAREAN SECTION (VBAC)

AIM

To standardize the management of a pregnant patient who has had a previous

Caesarean Section (C/S).

OUTCOME

In order to improve the outcome for mother and baby, these guidelines and
protocols will be adopted for use at all levels of health facilities with 24-hour
service of C/S.

DEFINITION

Vaginal Birth after Caesarean (VBAC) is the practice of birthing a baby vaginally
after a previous delivery through caesarean section.

28
The American College of Obstetricians and Gynecologists (ACOG) explains that "at
an individual level VBAC is associated with decreased maternal morbidity and a
decreased risk of complications in future pregnancies.”

VBAC is associated with an approximately 1 in 200 (0.5%) risk of uterine rupture.

Absolute risk of birth-related perinatal death associated with VBAC is extremely

low and comparable to the risk for nulliparous women in labour. (RCOG)

CONTRAINDICATIONS TO VAGINAL BIRTH AFTER PREVIOUS CAESAREAN

SECTION

● If the previous indication was of a recurrent nature, e.g., cephalo-pelvic

disproportion (CPD) due to contracted pelvis, vesicovaginal fistula, recto-
vaginal fistula, repaired 3rd degree vaginal tears.
● Two or more previous C/S.
● Previous hysterotomy.
● Classical scar (vertical incision on the uterus).
● History of sepsis following the previous C/S.
● Malpresentation and malposition, including breech.
● Multiple pregnancy.
● Macrosomia. (Baby > 4kg)
CONDITIONS WHERE VBAC (TRIAL OF SCAR) CAN BE CONSIDERED

● Patient may have VBAC (trial of scar) if the causes for the previous C/S are
non-recurring, e.g., malpresentation, fetal distress, cord prolapse, failure to
progress, severe pregnancy-induced hypertension or eclampsia, and twins
with abnormal lie of the first twin.

PREREQUISITES FOR ALLOWING PATIENT TO HAVE VBAC

● Patient informed consent.

● Theatre facilities for emergency C/S and blood products must be available, 24
hours.
● Experienced Medical Officer able to do emergency C/S must be available.
● There must be no other obstetric problems in the current pregnancy e.g. pre-
eclampsia, APH
● Cephalic presentation.
● Average size fetus.
● Clinically adequate pelvis.
● Strict intrapartum fetal heart monitoring (ideally continuous).

MANAGEMENT

DURING THE ANTENATAL PERIOD

29
● Take a comprehensive history and critical assessment as early as possible to
determine:
o Reason for previous C/S, type of C/S.
o Outcome: complications, if any, intra- and post-operatively.
o Possible puerperal infection.
● Reassess the option of allowing VBAC at every visit.
● Obtain informed consent and discuss the birth plan.
● Refer to hospital at 36 weeks for final decision on mode of delivery.
● All patients with a previous C/S must be delivered in hospital with
facilities for C/S.
● Patient should be seen by the Doctor who will assess the patient and decide
on the possible mode(s) of delivery at term.
● At 38 weeks estimate the weight of the fetus.
● Counsel the patient to come to the hospital early if she experiences anything
unusual or enters premature labour.

MANAGEMENT DURING LABOUR AND DELIVERY

● All patients with a previous C/S must be delivered in hospital.

● Patients selected for VBAC should also be admitted at 38 weeks if they are
staying far from the hospital. If a patient for VBAC has easy access to hospital,
however, she may stay at home and be instructed to present herself to
hospital at the first sign of labor, or rupture of membranes or haemorrhage.
● Get informed consent for VBAC if not obtained during the antenatal.
● Do HB, platelet count, grouping and cross-match.
● Insert I.V line.
● Oral clear fluid.
● Catheterize patient.
● Continuous fetal monitoring.
● STRICTLY monitor the progress of labour using the partograph.
● Observe closely for signs of uterine rupture, e.g., abdominal tenderness,
sudden cessation of contractions, maternal tachycardia, hypotension,
haematuria, fetal tachycardia or bradycardia and fetal death.
● Avoid induction of labour.

Perform emergency C/S if: Progress of labour is unsatisfactory or any other

indication

POST DELIVERY

● Observe the patient closely for post-partum haemorrhage which could be due
to uterine rupture during 2nd stage of labour.
● Prophylactic 10-40 IU of IV oxytocin in a drip
● Patient should remain in the ward for at least 24 hours.

30
 ____________
The Ministry of Health SRH Unit coordinated the development of these
Guidelines and Protocols in August 2015.

CHAPTER 8: MANAGEMENT OF
PROLONGED LABOUR and OBSTRUCTED LABOUR

PROLONGED LABOUR (POOR PROGRESS)

AIM

To standardize the management of prolonged labour.

OUTCOME

In order to improve outcome for mother and child, this protocol will be adopted
for use at all levels.

DEFINITIONS

It is established labour of over 12hrs or an active phase of over 6 hours

31
 ● Established labour is a stage when they are regular contractions
occurring every 3 /10mins for a duration of 45 to 55 seconds. There is
irreversible change of the cervix and cannot be abolished by analgesia

● Active labour is a stage when the cervix is 4cms dilated, fully effaced,
contractions are regular, 3/10mins with duration of 45 to 55seconds

● Use a partograph to monitor progress of labour. If the action line is reached, take
appropriate action:

MANAGEMENT

Use 4p’s assessment (patient, power, passage and passenger)

PATIENT

● Exhaustion and dehydration - rehydrate appropriately.

● Pain – Analgesia (Pethidine 50-100mg I.M plus hydroxyzine 50 -100mg IM).
● Full bladder – empty the bladder.
● Anxiety – Reassure, involve a family member.(carefully examine patient to
exclude possible cerebral hypoxia)

POWER

● Where possible, amniotomy should precede augmentation of labour

● Augmentation if no cephalo-pelvic disproportion (CPD) or other contraindications.

Primigravida: Dose: 5 IU oxytocin in 1L R/L. Start with 10 drops/minute for 30

minutes, then increase to 20 drops/minute for 30minutes and maintain at 40
drops per minute.

Reassess in 2 hours; if no change, increase to 10 units and repeat the above

dosing schedule OR

32
5IU Oxytocin in 1L R/L. Start at 60mls/hr and increase by 60mls/hr every
30mins until at least 3 moderate contractions in 10mins. Maximum rate is
240mls/hr

Alternatively: 10 units in 1 L R/L at 15, 30, 60 drops/minute. Titrate according

to contractions.

For Para 1 – 4: Start at 2.5 IU oxytocin with either of the above dosing schedules.

≥Para 5: Augmentation is at the discretion of the obstetrician

● Close fetal heart monitoring with either continuous CTG or pinard stethoscope
(every 15 minutes)
● If fetal distress is detected STOP augmentation, proceed to C/S.
● If the labour is augmented: after 2 hours reassess for descent of the
presenting part, cervical dilatation, excessive moulding, caput and cervical
oedema. If no progress, perform C/S.

PASSAGE

● Contracted pelvis (CPD) – do C/S.

● Pelvic tumors - do C/S.
● Soft tissue: augmentation, perform episiotomy if necessary, assisted delivery by
vacuum extraction or forceps delivery.
Note: Assisted delivery accounts for 10-15% of total deliveries worldwide.

PASSENGER

Perform C/S if:

● Malpresentation. e.g. face presentation, brow presentation

● Malpositions e.g., deep transverse arrest ( persistent OT)
● Macrosomia (>4kg).
● Congenital abnormalities e.g. hydrocephalus, cystic hygroma, conjoined twins.

____________

33
The Ministry of Health SRH Unit coordinated the development of these
Guidelines and Protocols in August 2015.

CHAPTER 9: OBSTRUCTED LABOUR

AIM

To standardize the management of obstructed labour.

OUTCOME

In order to improve outcome for mother and child, these guidelines and
protocols will be adopted for use at referral intermediate and district hospitals.

DEFINITION

Obstructed labour is prolonged labour that has been neglected

WE SHOULD AVOID GETTING TO OBSTRUCTED LABOUR

34
CLINICAL FINDINGS

The following may be present:

● Patient exhausted, dehydrated and anxious.

● Abdominal examination: may find Bandl’s ring, absent contractions, tender abdomen
for multiparous.
● Fetal heart: may be bradycardia, tachycardia or absent.
● Per vaginal inspection: vulval oedema, overt bleeding, foul smelling discharge,
meconium
● Digital vaginal examination: oedematous cervix, excessive caput or moulding,
meconium and blood.

MANAGEMENT

● ABC.
● IV antibiotics Ampicillin 1g IV stat or IV Clindamycin 600mg stat if allergic to
penicillin,
● Give IV Metronidazole 500mg 8hrly for 72hours.
● Insert bladder catheter.
● Monitor vital signs.
● Measure and record fluid intake, urinary output.
● Check fetal heart sounds
● Counsel/comfort patient.
● Obtain signed consent for C/S.
● Draw blood for Hb, if needed do grouping and cross-match.
● Prepare for C/S.
● If baby is alive: Prepare to resuscitate the baby when born.
● If uterine rupture, appropriate intervention should be taken by a senior member of
the team.

Post-operative

● Prevent PPH and administer 10-40 units of oxytocin in the 1st 1L N/S in the first
8hrs (125mls/ hour)
● Observe patient for PPH and manage accordingly.
● Maintain IV antibiotics for at least 3 days, and then change to oral to complete the
course.
● Continuous bladder drainage for at least 10-14 days.

Potential complications

Uterine rupture, VVF, RVF, IUFD, Sepsis, PPH

35
____________

The Ministry of Health SRH Unit coordinated the development of these

Guidelines and Protocols in August 2015.

CHAPTER 10: ANTEPARTUM HAEMORRHAGE

AIM

To standardize the management of antepartum haemorrhage

OUTCOME

In order to improve the outcome for mother and baby, these guidelines and
protocols will be adopted for use at all levels of health care facilities.

DEFINITION

Antepartum haemorrhage (APH) is bleeding from or into the genital tract, occurring
from 28 weeks of pregnancy until before delivery of the baby.

APH may be classified as:

● Spotting—staining, streaking, blood spotting on underwear or sanitary pad.

● Minor hemorrhage—blood loss less than 50 ml that has settled.
● Major hemorrhage—blood loss of 50-1000 ml with no signs of clinical shock
● Massive hemorrhage—blood loss greater than 1000 ml and/or signs of clinical
shock.
Causes of APH:

36
● Placental causes: Placenta praevia, Abruptio placentae and vasapraevia
● Non-placental causes: cervicitis, cervical erosions or polyps, cervical cancer,
vulva varicosities, trauma (post-coital/GBV or other causes) and
haemorrhoids.
NOTE: ANY BLEEDING IN A PREGNANT WOMAN SHOULD BE TAKEN
SERIOUSLY.

GENERAL MANAGEMENT

● Follow A, B, C:
o Airways clear
o Breathing
o Circulation
● Assess the haemodynamic status of the patient.
● Vital signs: pulse, blood pressure and do urgent ward HB. NOTE: Tachycardia
should be taken seriously even in a stable looking patient. Confusion and
restlessness may be early indications of cerebral hypoxia.
● Resuscitate the patient, if needed.
o Insert 2 peripheral lines using cannulae size 14—16 (if major/massive
haemorrhage).
o Correct hypovolaemia using crystalloids e.g. normal saline, Ringer’s
Lactate or colloids e.g. haemacel.
o Strict fluid balance chart. Insert Foleys catheter. Monitor input and
output. Note: output should be at least 30 mls per hour.
o Give oxygen 4 to 6 L per minute to the mother by facemask to improve
oxygenation to the fetus.
o Blood grouping and cross match, U&E, FBC, if platelet count is low, do
clotting profile.

NOTE: DO NOT PERFORM DIGITAL VAGINAL EXAMINATION UNTIL PLACENTA

PRAEVIA IS RULED OUT.

● Take detailed history to determine the probable cause.

● Conduct detailed physical examination including gentle speculum examination.
● Ensure fetal well-being.
● Do abdominal USG to determine placenta localization.

THE MAJOR CAUSES OF APH ARE PLACENTA PRAEVIA AND ABRUPTIO

PLACENTAE

37
SPECIFIC MANAGEMENT OF APH CAUSES

1. PLACENTA PRAEVIA
Definition: This refers to a situation where the placenta is partially or wholly
covering the internal os below presenting part.

● Diagnosis is made clinically as shown in the table above.

● Diagnosis is confirmed by ultrasound examination.
Grading of Placenta Praevia

Grade Description

I Placenta is in lower segment, but the lower edge does not reach
internal os

II Lower edge of placenta reaches internal os, but does not cover
it

III Placenta covers internal os partially

IV Placenta covers internal os completely

38
MANAGEMENT OF PLACENTA PRAEVIA

● Resuscitate depending on blood loss.

● Avoid digital vaginal examination
● Keep as inpatient on strict bed rest.
● Correct anaemia to ensure the HB is maintained above 11g/dl.
● Administer steroids if <38 weeks.
● Manage expectantly until fetal maturity if no major bleeding and fetal condition
is satisfactory.
● In case of life-threatening bleeding, deliver immediately, regardless of the
maturity of the fetus.
● Depending on the grading of placenta praevia, deliver by elective caesarean
section at 38 weeks. (Grade 1 and 2 anterior may be allowed to deliver vaginally.)
● Have at least two units of cross matched packed cells before C/S.
● Caesarean section to be performed by the most senior doctor or consultant
available.

ABRUPTIO PLACENTAE

Definition: Premature separation of a normally implanted placenta.

Grading of Abruptio Placentae

Grade Description

1 No signs or symptoms of abruption placenta present. Diagnosis is made

in retrospect.

2 Signs of abruption present, i.e., minimal bleeding, abdominal pain and

irritable uterus + live baby.

3 Fetal death, no vaginal bleeding to heavy vaginal bleeding, very painful

tetanic uterus, maternal shock.

3a: No coagulopathy.

3b: Evidence of coagulopathy (DIC).

MANAGEMENT OF ABRUPTIO PLACENTAE

39
1. Management is based on above grades.
● Grade 2 – Live viable fetus: emergency caesarean section after insertion of
two IVI access lines + Foley catheter. Draw blood for FBC, U&E and cross-
match. Patients may be allowed to deliver vaginally in selected cases,
e.g., patients in advanced labour and there is no evidence of fetal
distress.
● Grades 3 – Allow normal vaginal delivery unless indications for caesarean
section exist, e.g., major mal-presentation, uncontrollable BP, uncontrollable
bleeding, recurrent clotting defect despite correction.
In all cases note the following.
● Where Bishop Score is favourable, rupture membranes and augment to
expedite labour
● Give strong analgesia such as Pethidine 100mg or morphine 15mg
● Delivery must be achieved within 6-10 hours of admission.
● Manage 3rd stage of labour actively.
● Explore genital tract for lacerations and tears as the delivery is often
explosive.
● Keep patient on oxytocin drip with 20-40 units until 24 hours post-delivery
(125mls/hour).
● Administer prophylactic antibiotics if indicated.

NOTE: IN ALL CASES OF APH

● Post-delivery: continue resuscitation + strict monitoring of vital signs (BP,

pulse, urine output) as there is a risk for PPH.
● Administer Anti-D Immunoglobulin to all non-sensitized Rhesus D-negative
women after any presentation of APH.

____________
The Ministry of Health SRH Unit coordinated the development of these
Guidelines and Protocols in August 2015.

40
CHAPTER 11: POST-PARTUM HAEMORRHAGE (PPH)
AIM

To standardize the management of post-partum haemorrhage.

OUTCOME

In order to improve the outcome for mother and baby, these guidelines and
protocols will be adopted for use at the local and regional level.

DEFINITION

PPH is a bleed of more than 500 mL following normal vaginal delivery or more
than 1000 mL following C/S, or enough blood loss to make the patient
symptomatic.

RISK FACTORS
● Prolonged labour
● Macrosomic baby
● Previous PPH
● Multiple pregnancy
● Labour induction
● Retained placenta
● Placenta accrete
● Abruption placenta

MANAGEMENT

IF A PATIENT IS AT RISK FOR PPH START I.V. LINE IN ADVANCE:

● Shout for assistance. State “PPH.”
● Clear the airway and ensure that the patient is breathing.

41
 ● Secure an I.V. line using wide bore cannula size 14-18 or widest cannula
available.
● Draw blood for.
o Cross-match and book 3 units.
o Full blood count, urea and electrolytes
o Clotting profile.
● Insert a urinary catheter to empty the bladder and to monitor urine
output.
Examine the patient for source of bleeding (4 Ts -Tone, Tissue, Trauma,
Thrombin)
● If it is uterine atony
o Massage the uterus
o Repeat oxytocin: Bolus 10 units I.V, then:
20 IU in 1L Ringer’s lactate at a rate of 2 mL/minute (20-40 drops)
for 24 hours. Monitor urine output.
o Reassess the patient. If no response in 10 minutes, administer
ergometrine (0.5mg IM)
but USE with caution for pre-eclampsia patient or other
hypertensive patients.
● If no response, give Misoprostol (4 x 200 mcg) PR.
● Ensure that the placenta is complete.
● If bleeding persists and/or the patient has hypotension:
o -Open another I.V. line; administer plasma expander 500 ml over
30 minutes, to maximum of 1L as you wait to transfuse.
o -Restore and maintain BP with I.V. fluids (normal saline/Ringers
lactate, 1 L in first hour, monitor).
● If bleeding persists despite above interventions, refer to higher level.

ABDOMINAL AND PELVIC EXAMINATION TO DETERMINE:

● Atonic uterus,
● Lacerations or
● Inverted uterus

IF ATONIC UTERUS (uterus large and soft):

● Bimanual compression as temporary measure.
● Contact Senior Doctor/Consultant.
● Continuous massage of the uterus.
● Evacuate clots.
● Senior Doctor/Consultant to consider other interventions.

IF LACERATIONS (uterus well contracted):

● Bimanual compression with packing.
● Find source of bleeding: uterus, cervix, vagina.
● Repair lacerations.

42
IF INVERTED UTERUS (uterus not felt):
● Reduce immediately. To do so:
● Wear sterile glove.
● Push uterus back into position.
● Massage.
● Bleeding should then be reduced.

For severe PPH, move patient to high-care unit/ICU.

When the patient is stable, chart fluid input/output to avoid fluid overload and
pulmonary oedema.
Document steps thoroughly: date, time, name and signature.

NB: where PPH is likely to occur (e.g. > Para 5, over distended uterus, previous
C/S, prevent PPH by putting up 1L Normal saline with 20-40IU of oxytocin.

____________

The Ministry of Health SRH Unit coordinated the development of these

Guidelines and Protocols in August 2015.

43
CHAPTER 12: SEVERE PRE-ECLAMPSIA/ECLAMPSIA
AIM
To standardize the management of severe preeclampsia/eclampsia in the
immediate pre- and post-delivery interval.

OUTCOME
In order to improve the outcome for mother and baby, these guidelines and
protocols will be adopted for use at all levels.
DEFINITION
Pre-eclampsia is new hypertension presenting after 20 weeks gestation with
significant proteinuria with or without oedema and can present as late as 4-
6weeks postpartum.

1. Mild pre-eclampsia
● BP of ≥ 140/90 on ≥2 occasions measured at least 6hrs apart but
without evidence of end organ damage in women with previously
normal BP before 20 weeks gestation
OR

● An increase in Systolic BP by 30mmHg or of DBP by 15mmHg

2. Severe pre-eclampsia: any 1 of the following in the presence of pre-
eclampsia
● SBP ≥ 160mmHg or DBP of ≥110mmHG on2 occasions at least 6hrs
apart
● Proteinuria >5g in a 24hr urine collection or 3+ on 2 random urine
samples collected at least 4hrs apart
● Pulmonary oedema/ cyanosis
● Urine output <30mls/hr (oliguria)
● Persistent headaches
● Epigastric pain +/- impaired liver function
● Oligohydramnios,
● Decreased fetal growth
● Placental abruption
● Thrombocytopenia
3. Eclampsia: seizures that cannot be attributed to other causes in a woman
with preeclampsia

RISK FACTORS:
● 1st pregnancy
● Age >40yrs
● Overweight (BMI >35 at 1st ANC visit)

44
 ● Family history of PIH/ pre-eclampsia
● Multiple pregnancy
● Last pregnancy was> 10 years ago
● Chronic kidney disease
● Diabetes Mellitus
● Autoimmune diseases
● Race -black
● Chronic hypertension

SYMPTOMS:
● May be asymptomatic
● Headache not relieved by simple analgesia
● Altered mental state
● Blindness
● Shortness of breath
● Blurred vision or flashing
● Epigastric pain
● Heartburn or Right upper quadrant abdominal pain not relieved by
antacids
● Rapid swelling of face, hands and feet
● Nonspecific complaints of being unwell which may be due to haemolytic
anaemia
● Hyperreflexia and/ or Clonus which may indicate imminent convulsions

MANAGEMENT OF MILD TO MODERATE PRE ECLAMPSIA:

Deliver all patients with mild and moderate eclampsia at 37 weeks gestation
however, this can be done earlier where there are signs of worsening
maternal condition and fetal compromise

MANAGEMENT OF SEVERE PRE-ECLAMPSIA AND ECLAMPSIA

● Do not leave the patient alone.
● Shout for assistance. State “Eclampsia”
● Turn patient to left lateral position.
● Ensure that the airway is clear and the patient breathing.
● Ask assistant to call the doctor to come immediately.
● Doctor to request help of other staff.

● If the patient is not breathing, use an Ambu-bag and mask until the
patient is intubated and ventilated.
● Protect the patient from falling, injury.
● Do not place anything in the mouth.
● Oxygen by mask at 4-6 L per minute.
● When convulsion ends, start IV.

45
 ● Take vital signs.
● Give Magnesium Sulphate as follows:-

IV Route:
● Start loading dose (bolus) of Magnesium Sulphate.
● By IV: 4 g Magnesium Sulphate in 200 ml normal saline, run it over 5-10
minutes. Double-check the dose with another health professional.
● Explain urgent treatment to family members.
● Maintenance dose after the loading dose of magnesium Sulphate is
given until 24 hours after the last convulsion.
o By IV: add 10g MgSO4 to 200mls N/S and run infusion at 20mls/hr.
(Equivalent to 1g/hr). Treatment should continue for 24hrs from
the last convulsion or delivery whichever comes later. Label the
bottle that it has MgSO4.

OR

IM Route :
Loading dose:
● 4 g Magnesium Sulphate in 200 ml normal saline, run it over 5-10,
followed immediately by
o 5g IMI in each buttock, (total dose of 14g.)
o Maintenance dose 5g in alternate buttocks 4 hourly in 24 hours.
Before each maintenance dose, check knee reflexes, urine output ≥
25mls/Hr.

If convulsions recur during the course of maintenance phase, give a bolus of IV

infusion 2g MgSO4 in 100ml normal saline slowly in 5 minutes. Repeat the bolus
dose every time there is a convulsion.
● Monitor closely for MgSO4 toxicity (patella reflexes, respiratory rate
≥16breathes/min, and level of consciousness). Antidote for MgSO4 toxicity is
Calcium Gluconate which should be readily available. Given as bolus 10mls
over 10 minutes.
● Insert indwelling catheter to monitor urine output hourly.
● If diastolic BP is 110 or higher, give medication to bring it down. Aim at
diastolic BP of 90-100mmHg. May use:
● Hydralazine IVI, or Nifedipine PO, or Labetalol IVI or PO.
Administer either: Dihydralazine injection as
o Initial dose 6.25 mg IV in 10 mL sterile water administered slowly
over 4 minutes.
o Repeat dose after 30 minutes if necessary

Note: Preload with I.V. NS/R/L 500mls stat before giving hydralazine.

Mix 1 ampoule (25 mg) hydralazine in 200 mL normal saline.

46
Start infusion slowly at 20mls/hr.

Discontinue infusion when diastolic is 90mmHg

If hydralazine is not available, the following regimes can be used:

o Nifedipine 10 mg PO (not sublingual). Observe BP carefully.

o Labetalol infusion (if available) 200 mg in 200 mL saline at 5 drops
per minute.
● Draw blood for full blood count, urea and electrolytes, LFTs and clotting
profile.
● Every hour auscultate to the lungs for rales at base of lungs.
● Fluid restriction is advised (80mL/hr or 1ml/kg/hr)
● Urine output should be >30ml/hr.

When the patient is stable (normal BP, adequate urine output, blood profile
results available, cardiopulmonary function, fitting stopped):
● Look for signs of abruption placenta.
● Make decision on mode of delivery (assess the favourability of the cervix)
-If gestational age <34 weeks, give steroids and deliver baby within 48 hours in
sever pre-eclampsia if stable. For eclampsia deliver within 12hrs
Deliver by the most expeditious route (NVD or C/S).

Endeavour to use Automated Blood Pressure measuring machines at all times

when monitoring these patients (monitor every 15 minutes).

Remember that 1ml = 15 – 20 drops of fluids.

MANAGEMENT OF 3RD STAGE

Give 10 IU I.M Syntocinon.

(Do not use Ergometrine; it increases BP.)

POST-DELIVERY MANAGEMENT
Be aware for late convulsions.
Continue MgSO4 until 24 hours after delivery or last fit, or 24 hours after
initiation of MgSO4 if patient never fitted.
Reassess the need for antihypertensive after delivery (see medications noted
above).

CRITERIA FOR TRANSFER TO ICU OR High Care

The patient should be transferred to ICU or well-equipped High Care Unit if there
are:-
▪ Recurrent seizures on treatment
▪ Mean Arterial Pressure (MAP) >125 despite hydralazine, Nifedipine and
Labetalol.
▪ Pulmonary oedema (clinically or falling oxygen tension) with oliguria.

47
▪ Oliguric with normal CVP unresponsive to dopamine.
▪ Glasgow Coma Scale of ≤ 8
▪ Compromised myocardial function.

Termination of pregnancy is the ultimate treatment of severe Pre-Eclampsia or

Eclampsia. The most appropriate route should be used to expedite delivery at
any gestation. Maternal safety overrides that of the foetus.
Eclamptic patients should be delivered as soon as possible after stabilisation
(within 4-6hrs), that is,

● There are no further convulsions

● Urine output is satisfactory
● The cardio-respiratory systems are normal.

Post-Partum
Monitor BP and proteinuria. If BP is elevated, refer to physician for further
investigation.

Follow up
Keep patient in the ward until all biochemical tests revert to normal
On discharge:
o Check BP daily at clinic level
o Review at hospital within the week
o If BP is normal after 1 week, review at clinic twice weekly until 6weeks, if
BP still abnormal, refer to physician

____________

The Ministry of Health SRH Unit coordinated the development of these

Guidelines and Protocols in August 2015.

CHAPTER 13: FLUID MANAGEMENT IN CRITICALLY

ILL PATIENT

OBJECTIVE
To improve fluid management in critically ill patients

KEY THINGS TO BEAR IN MIND ARE:

1. The management of these patients must be anticipatory and a multi-
disciplinary approach

48
 2. Use goal-directed fluid therapy in critical care patients
a. have a 24hour plan of fluid therapy
b. specify clearly what to give (type of fluid), how much to give (flow
rate)
3. Recognize the potential for fluid overload and its associated risks.
4. Select appropriate fluids for resuscitation.
5. Assess renal function in patients with fluid imbalance.

THREE GOALS IN THE MANAGEMENT OF CRITICAL PATIENTS:

1. Maximize oxygen delivery
2. Control further blood loss, and
3. Fluid resuscitation.

USE OF FLUIDS:
Have to account for several factors:
▪ Deficit
▪ Maintenance
▪ 3rd space ongoing losses
▪ Blood loss

INITIAL RESUSCITATION GOALS INCLUDE:

● MAP (mean arterial pressure) > 65 good for vital organ perfusion.
o MAP = 2x DBP + 1x SBP OR 2/3 DBP + 1/3 SBP
3
Example; if BP 120/60, the MAP = 2x60 + 120 = 240 = 80mmHg
3 3
OR MAP = 2/3 x 60 + 1/3 x 120 = 40 + 40 = 80mmHg

● Urine output > 0.5ml/kg

● Attaining central venous pressure of 8 to 12 mm Hg if available
● Resuscitation fluid used initially should remain as crystalloid N/S or R/L
at 20ml/kg as bolus though in sepsis can go up to 30ml/kg.
● Monitor input and output: You want well balanced fluids to avoid
overload. Allow positive balance on patient who was previously behind.

How do you calculate this?

Fluid replacement should continue at the initial rapid rate as long as the systemic
blood pressure remains low. Clinical signs, including blood pressure, urine
output, mental status, and peripheral perfusion, are often adequate to guide
resuscitation.

MAINTENANCE
4‐2‐1‐ rule gives you maintenance rate.
Note: this is maintenance and losses should be accounted for and added
to maintenance
4ml/kg/hr for the 1st 10kg
49
 2ml/kg/hr for the 2nd 10kg
1ml/kg/hr for every kg above 20kg/ the remaining kgs

Example; for a 70kg

Maintenance for this patient will be as follows;
1st 10kg = 4ml x 10 = 40ml/hr
2nd 10kg = 2ml x 10 = 20ml/hr
Balance 50 kg = 1ml x 50 = 50ml/hr
TOTAL = 40 + 20 + 50 = 110ml/hr (this patient must get 110ml/hr of fluid but in
pre-eclampsia the limit is 85ml/hr)

ASSESSMENT AND MONITORING OF FLUID BALANCE

History Alerts to likelihood of fluid deficit (e. g.

vomiting/diarrhoea/haemorrhage) or
excess (e. g. from intraoperative fluids)
Autonomic Responses Pallor and sweating, particularly when
combined with tachycardia, hypotension
and oliguria are suggestive of intravascular
volume deficit,
Capillary refill Slow refill is compatible with, but not
diagnostic of volume deficit. Can be
influenced by temperature and peripheral
vascular disease
Blood pressure Nonetheless, a fall is compatible with
intravascular hypovolemia, particularly
when it correlates with other parameters
such as pulse rate, urine output, etc.
NB: Systolic pressure does not usually
fall until 30% of blood volume has been
lost.
Urine output <30 ml/h (<0.5 ml/kg/h) is commonly used
as indication for fluid infusion, and signals
intra - vascular hypovolaemia. Urine quality
(e.g. concentration, urine: plasma urea or
osmolality ratio) is just as important,
particularly in the complicated patient.

Consequences of fluid mismanagement to be reported as critical incidents

Consequence Identifying features Time frame of

of fluid identification
mismanageme
nt

Hypovolaemia ● Patient's fluid needs not met by oral, Before and during
enteral or IV intake and IV fluid therapy
● Features of dehydration on clinical
examination

50
 ● Low urine output or concentrated urine
● Biochemical indicators, such as more
than 50% increase in urea or creatinine
with no other identifiable cause
Pulmonary ● No other obvious cause identified (for During IV fluid
oedema example, pneumonia, pulmonary therapy or within
(breathlessness embolus or asthma) 6 hours of stopping
during ● Features of pulmonary oedema on IV fluids
infusion) clinical examination
● Features of pulmonary oedema on X-ray
Hyponatraemia ● Serum sodium less than 130 mmol/l During IV fluid
● No other likely cause of hyponatraemia therapy or within
identified 24 hours of
stopping IV fluids
Hypernatraemi ● Serum sodium 155 mmol/l or more During IV fluid
a ● Baseline sodium normal or low therapy or within
● IV fluid regimen included 0.9% sodium 24 hours of
chloride stopping IV fluids
● No other likely cause of hypernatraemia
identified
Peripheral ● Pitting oedema in extremities and/or During IV fluid
oedema lumbar sacral area therapy or within
● No other obvious cause identified (for 24 hours of
example, nephrotic syndrome or known stopping IV fluids
cardiac failure)
Hyperkalaemia ● Serum potassium more than 5.5 mmol/l During IV fluid
● No other obvious cause identified therapy or within
24 hours of
stopping IV fluids
Hypokalaemia ● Serum potassium less than 3.0 mmol/l During IV fluid
likely to be due to infusion of fluids therapy or within
without adequate potassium provision 24 hours of
● No other obvious cause (for example, stopping IV fluids
potassium-wasting diuretics, refeeding
syndrome)

____________

The Ministry of Health SRH Unit coordinated the development of these

Guidelines and Protocols in January 2016.
.

CHAPTER 14: MANAGEMENT OF ANAEMIA IN

PREGNANCY

AIM

51
- To standardise management of anaemia in pregnancy in the Swaziland
setting
- All women must have an HB of > 11 g/dl at term
DEFINITION

Anaemia is defined as haemoglobin level less than 11g/dl

OR

HB <11g/dl in 1st trimester

HB <10.5g/dl in 2nd trimester

HB <11g/dl in 3rd trimester

SYMPTOMS

The signs and symptoms are often non-specific with tiredness being the most
common. Women may also complain of weakness, headaches, palpitations,
dizziness, dyspnoea and hair loss.

MANAGEMENT AT ANC VISIT

● Prophylaxis – all pregnant women should be put on iron and folate

supplements
o Ferrous sulphate 200mg po OD Or
o Ferrous fumarate 210mg po OD Or
o Ferrous gluconate 200mg po OD
● FBC at booking visit, 28weeks, and 36weeks of gestation. Women with
multiple pregnancies should have an additional full blood count done at
20–24 week. Women with a normal Hb but a low MCV should have their
ferritin checked and if ferritin is <30μ/l, oral iron should be commenced.
HB<7g/dl:
- Iron supplementation and refer
- Transfuse at least 2 units of blood if symptomatic or actively
bleeding, but if at term transfuse regardless of symptoms.
Hb<9g/dl: increase iron supplementation where applicable and refer if
symptomatic
● For MCV ≤100FL, a trial of oral iron should be considered as the first step
and further tests should be undertaken if there is no demonstrable rise in
Hb at 3 week ANC visit and compliance has been checked. REFER TO
OBSTETRICIAN IF HB IS STILL LOW

Treatment Drug doses: Ferrous Sulphate 200mg po tds OR

Ferrous Fumarate 210mg po tds OR
Ferrous Gluconate 600mg po tds
N.B. if 200mg ferrous Sulphate used, if taken correctly will give a rise in Hb of
2g/dl every 3weeks. This should be on an empty stomach, 1 hour before meals,
with a source of vitamin C to maximise absorption.

52
If there is no response after 3 weeks with adequate iron supplementation
consider other causes of anaemia.

● Continue Iron treatment for at least 3months

● Diet counselling during ANC
● ADVISE TO DELIVER AT HOSPITAL WITH TRANSFUSION FACILITIES
MANAGEMENT OF LABOUR AND DELIVERY

Note: All women must have an HB of > 11 g/dl at term

● Group, cross match and hold

● Insert wide bore cannula
● Active management of 3rd stage of labour
● If PPH occurs act quickly (refer to PPH SOP)
● Post-delivery, start an oxytocin infusion (20U in 1 R/L at
20-40drops/min) for 4 hours
POSTNATAL MANAGEMENT

● FBC 24hrs after delivery if:

PPH of >500mls
Uncorrected antenatal anaemia
Known iron deficiency anaemia
Any woman with signs or symptoms of anaemia
● HB 8-10g/dl: ferrous supplement for 3months. At 6week visit repeat FBC
● HB <8g/dl: give iron treatment and do FBC at 10days and 3months
● HB <7g/dl: discuss with mother and consider transfusion
Women who are symptomatic of anaemia, haemodynamically unstable or
continuing to bleed heavily will need to be reviewed by a senior practitioner for
a full obstetric review to investigate the origin of the blood loss and decide
further treatment.

The Ministry of Health SRH Unit coordinated the development of these

Guidelines and Protocols in January 2016.

CHAPTER 15:THE MANAGEMENT OF MISCARRIAGE

OBJECTIVE: to prevent morbidity or mortality from miscarriage (abortion)

This includes threatened, inevitable, incomplete, complete and missed.

DEFINITION:

Miscarriage is the termination of pregnancy before the age of fetal viability

estimated at less than 28 weeks gestation in Swaziland.

THREATENED MISCARRIAGE

53
 ● Definition: Bleeding in an intra-uterine pregnancy when the cervix is
closed and the fetus is alive.
● There is no specific treatment. Reassure the patient that if the fetal heart
is seen, there’s a 90% chance that the pregnancy may continue.
● Admit for bed rest.
● Avoid sexual intercourse for at least 2 weeks.
COMPLETE MISCARRIAGE

● Definition: Diagnosed if the patient has passed a conceptus or clots, the

pregnancy test is positive, the uterus is empty and an ectopic pregnancy
has been excluded.
● Explain to the patient what happened.
● Discharge patient home on antibiotics (erythromycin and metronidazole)
if clinically stable.
INEVITABLE AND INCOMPLETE MISCARRIAGE

● Definition:
o Inevitable - Bleeding of an intra-uterine pregnancy when the
cervix is open and products of conception have not been expelled.
Note: in cervical incompetence there may be no bleeding and no
pain.
o Incomplete - Bleeding in an intra-uterine pregnancy when the
cervix is open and products of conception have been partially
expelled.

MANAGEMENT

● Insert an IV line with 20 units oxytocin in 1 litre Ringer-Lactate

● Resuscitate with IV fluids using a 2nd IV line if there’s hypovolaemic shock
OR other indications
● Do FBC, Rhesus. If unstable also do U&E and cross-match
● Perform manual vacuum aspiration for all incomplete miscarriages who
are clinically stable, less than 14 weeks pregnant and haemoglobin
>9g/dl.
● Perform an evacuation for those who don’t fit the above criteria
● Give antibiotics : IV Ampicillin 500mg 6 hourly
IV Metronidazole 500mg 8hrly
● Ensure that patients who are severely anaemic are on blood transfusion
by the time they need to go for evacuation
● With inevitable miscarriage, perform the evacuation after expulsion of the
fetus

54
SEPTIC INCOMPLETE MISCARRIAGE

● Definition: Bleeding of an intra-uterine pregnancy when the cervix is open

and products of conception have been partially expelled associated with
sepsis
o Local sepsis – limited to the uterus and there are no signs of shock
o Systemic sepsis – generalized infection with or without shock
● Severe cases may rapidly go into septic shock and multiple organ failure.
● Signs are hypotension, offensive products, tachycardia, pyrexia and
tachypnoea
● Assess thoroughly for organ dysfunction – FBC,U&E, Chest X-ray ,blood
gases( look for DIC, renal failure, Acidosis)
● Hourly vital signs to identify septic shock
● Place an indwelling catheter and monitor urine output hourly
● Use a speculum to inspect the cervix for trauma and gangrene
● Give triple IV antibiotics:
a. IV Ampicillin 500mg 6 hourly
b. IV Metronidazole 500mg 8 hourly
c. IV Gentamycin 240mg daily
● Perform an evacuation at least 6 hours after administration of
antibiotics
● Consider hysterectomy if there’s a dusky or gangrenous cervix,
generalized peritonitis, failure of two or more organ systems or
uncontrollable bleeding.

MISSED MISCARRIAGE

● Definition: an intra-uterine pregnancy where the cervix is closed and

there is no fetal heart, no bleeding and no pain.
● There may be no fetus in gestation sac.
MANAGEMENT

Diagnosis

● Crown-rump length is 7mm or more and no visible heartbeat on

transvaginal ultrasound scan.
● The mean gestational sac diameter is 25mm or more and no visible fetal
pole on transvaginal ultrasound scan.
● Do not use gestational age from last menstrual period alone to determine
whether a fetal heart beat should be visible
Management options

First Trimester

55
1) Expectant management

● Use expectant management for 7-14 days as the first line of treatment
unless;
a) The woman is at risk of haemorrhage (e.g. late first trimester),
b) She is at increased risk from the effects of haemorrhage (e.g. if she has
coagulopathies or unable to have blood transfusion),
c) Expectant management is unacceptable to her.
● Explain to women undergoing expectant management what to expect and
provide pain relief.
● Advise women undergoing expectant management to return to hospital
for repeat ultrasound scan if pain and bleeding
a) Have not started in the 7-14 days
b) Are persisting or increasing (suggesting incomplete miscarriage).
● Repeat pregnancy test 3 weeks after resolution of the bleeding and pain.
2) Medical Management

● Give a single dose of 800mcg misoprostol orally or vaginally.

● Inform the patient about what to expect throughout the whole process,
including length and duration of bleeding and side effects (pain, vomiting
and diarrhea).
● Offer pain relief and anti-emetics
● Repeat pregnancy test after 3 weeks
3) Surgical Management

Manual Vacuum Aspiration OR

Suction curettage/ Dilatation and Curettage

Second trimester

● Use misoprostol 400mcg vaginally 6 hourly for up to 4 doses to allow

expulsion of the fetus.
● After fetus is expelled, assess for retained products of conception. If
present, perform an evacuation.
ON DISCHARGE OFFER ALL PATIENTS WHO HAVE BEEN TREATED FOR
MISCARRIAGE

● Counselling
● Contraception
● Anti – D if rhesus negative

____________

56
 The Ministry of Health SRH Unit coordinated the development of these
Guidelines and Protocols in January 2016.

CHAPTER16: PUERPERAL SEPSIS

AIM
To standardize the management of puerperal sepsis.

OUTCOME
In order to improve the outcome for mother and baby, these guidelines and
protocols will be adopted for use at the local and regional level.

DEFINITION
A bacterial infection occurring soon after delivery, up to 42 days post-partum. It
can be localized in the genital tract or systemic.

SYMPTOMS
Depend on whether it is localized or systemic. They may include: pelvic pain,
fever, abnormal discharge (vaginal, incision, breast), delay in reduction of uterus
size (involution).

57
 POSSIBLE RISK FACTORS
Pre-term and prolonged rupture of membranes, prolonged labour, immune
suppression, STI history, previous post-partum sepsis, and operative delivery.

MANAGEMENT
● ABC, vital signs, thorough history and physical examination.
● Classify if mild, moderate or severe infection (refer to algorithm)
● All HIV positive patients should be treated as if they have severe infection

If severe infection manage as follows:

● Put up an IV line and rehydrate with N/S, R/L. Rehydrate adequately as

guided by the urine output >30ml/hr.
● Strict fluid balance chart
● Admit patient.

● TREAT AGGRESSIVELY!
➢ May require high care/ICU.
➢ Septic workup: Blood culture, cervical swab to establish causative
organism, FBC, CRP, CXR, U&E urinalysis, malaria screen; determine the
HIV status if unknown.
➢ Other investigations: abdominal USG.
➢ Broad-spectrum antibiotics:
o Metronidazole IV 500 mg every 8 hours.
o Ampicillin 1g IV 6 hourly; if allergic to penicillin, give clindamycin
600mg 8 hourly.
o Gentamicin IV (8mg/kg) divided in 8 hours.
➢ Paracetamol 1 gram orally every 6 hours.
➢ Encourage bed rest. Make woman as comfortable as possible.
➢ Continue monitoring clinical condition and vital signs every 4 hours until
fever subsides.
➢ Adjust to appropriate antibiotics after the blood culture and sensitivity
results.
➢ Determine the severity of the infection; if mild, adjust to oral medication
after 48 hours.
➢ Continue antibiotics for 5-7 days.

❖ If not responding within 48 hours refer for appropriate care or consult a

specialist.

Specific treatment
● Evacuate if remaining products of conception are suspected (this should be done
at least 6-8 hours after initiation of antibiotics).

58
● If there is pelvic abscess, drain.
● Treat other possible sources of infection as appropriate.
Possible complications: Septic shock localized or generalized peritonitis, renal
failure, DIC, infertility, chronic pelvic pain, intestinal obstruction, dyspareunia,
etc.

____________

The Ministry of Health SRH Unit coordinated the development of these

Guidelines and Protocols in August 2015.

CHAPTER 17: MANAGEMENT OF SEVERE SEPSIS

AND SEPTIC SHOCK

OBJECTIVE:

To prevent and reduce morbidity and mortality from obstetric sepsis.

1. INTRODUCTION/DEFINITIONS
Infection is defined as a pathological process caused by invasion of normally
sterile tissue or fluid or body cavity by pathogenic or potentially pathogenic
microorganisms. It is important to point out that, frequently, infection is
strongly suspected without being microbiologically confirmed.

2. CLINICAL CRITERIA OF SEPSIS

Disorder Criteria

Systemic Inflammatory At least two of the following:

Response Syndrome
• Body temperature >38.5°C or <35.0°C
(SIRS)
• Heart rate >90 beats per minute
• Respiratory rate >20 breaths per minute or PaCO2<32
mmHg or a need for mechanical ventilation
• White blood cell count >12,000/mm3 or <4,000/mm3
or immature forms >10 percent

59
Sepsis is the clinical SIRS PLUS: documented infection based on either of the
syndrome defined by the following:
presence of both • Culture or Gram stain of blood, sputum, urine, or
infection and the normally sterile body fluid positive for pathogenic
systemic inflammatory microorganism
response syndrome • Focus of infection identified by visual inspection
(SIRS). (e.g. a ruptured bowel with free air or bowel
contents found in abdomen at surgery, or a wound
with purulent discharge)

Severe Sepsis: systemic Sepsis PLUS at least one of the following signs of organ
inflammation secondary hypo perfusion or organ dysfunction:
to infection combined
• Areas of mottled skin
with acute organ • Capillary refill time ≥3s
dysfunction. • Urinary output <0.5mL/kg for at least 1 hour or renal
replacement therapy
• Lactic acid levels >2mmol/L
• Abrupt change in mental status or abnormal
electroencephalogram (EEG)
• Platelet counts <100,000/mL or disseminated
intravascular coagulation (DIC)
• Acute lung injury (ALI) or acute respiratory distress
syndrome (ARDS)
• Cardiac dysfunction (echocardiography)
Septic Shock is severe Severe sepsis PLUS at least one of the following:
sepsis combined with
hypotension not • Systemic mean blood pressure <60mmHg (<80mmHg if
previous hypertension) after 20–30 mL/kg starch or
rectified by fluid 40–60 mL/kg serum saline, or pulmonary capillary
resuscitation. wedge pressure between 12 and 20 mm Hg
• Need for dopamine >5 μg/kg per minute or
norepinephrine or epinephrine <0.25μg/kg per minute
to maintain mean blood pressure above 60 mm Hg (80
mm Hg if previous hypertension)

3. SEPSIS IN OBSTETRIC PATIENT

Septic shock is relatively uncommon in maternity patients. However, it can be a
cause of maternal mortality.

The outcome and survivability in severe sepsis and septic shock in pregnancy are
improved with early detection, prompt recognition of the source of
infection, and targeted therapy. This improvement can be achieved by
formulating a stepwise approach that consists of:

● The involvement of a multi-disciplinary team

● early provision of time-sensitive interventions such as: aggressive
hydration (20 mL/kg of normal saline over the first hour),
● initiation of appropriate empiric intravenous antibiotics (gentamicin,
metronidazole, and penicillin) within 1 hour of diagnosis,

60
 ● central hemodynamic monitoring
Thorough physical examination and imaging techniques or empiric exploratory
laparotomy are suggested to identify the septic source.

3.1. RISK FACTORS FOR THE DEVELOPMENT OF SEPSIS IN PREGNANCY

Non-Pregnancy Pregnancy
Age > 35 Cervical Cerclage
Minority ethnic group PPROM
Vulnerable socio-economic background Retained products (e.g. septic
abortion)
Obesity History of group B Streptococcus
infection
Diabetes History of pelvic infection
Immunocompromised Group A Streptococcus infection in
close contacts
Chronic renal failure Amniocentesis
Chronic liver failure

Chronic heart failure

3.2. SOURCES OF MATERNAL INFECTION IN SEVERE

SEPSIS:

- Genito-urinary Tract
- Wound
- Respiratory system

4. MANAGEMENT
Sepsis is better managed in PACKAGE of TREATMENT.

a. SEPSIS RESUSCITATION: to be completed 100 percent within the first

six hours of treatment.
▪ Measure Serum Lactate. Begin resuscitation immediately in patients with
hypotension or elevated serum lactate >4 mmol/L; do not delay pending
ICU admission
▪ Obtain blood cultures prior to broad-spectrum
antibiotic administration
▪ Treat hypotension and/or elevated lactate with fluids, and apply
vasopressors for ongoing hypotension

61
 o Give fluid challenges of 1,000 mL of crystalloids or 300–500 mL of
colloids over 30 minutes. More rapid and larger volumes may be
required in sepsis-induced tissue hypoperfusion

RESUSCITATION GOALS:

o CVP 8–12 mm Hg (A higher target CVP of 12–15 mm Hg is

recommended in the presence of mechanical ventilation or preexisting
decreased ventricular compliance.)
o Mean arterial pressure ≥ 65 mm Hg
o Urine output ≥0.5 mL/kg/hr.
o Central venous (superior vena cava) oxygen saturation ≥70 percent or
mixed venous ≥65 percent

b) SEPSIS MANAGEMENT: to be completed within

the first 24h.
Administer steroids (not more than 300mg hydrocortisone per day).
Do not use steroids to treat sepsis in the absence of shock.
1) Administer recombinant human activated protein C(rhAPC) subject to
availability.
2) Glucose control
● Use intravenous insulin to control hyperglycaemia.
● In patients with severe sepsis following stabilization provide a glucose
calorie source and monitor blood glucose values every 1–2 hours (4
hourly when stable) in patients receiving intravenous insulin. Maintain
glucose control with a goal blood glucose approximating 8mmol/L with a
recommendation against intravenous insulin therapy titrated to keep
blood glucose in the normal range (4 – 7 mmol/L) in patients with severe
sepsis. Clinicians should consider initiating insulin therapy when blood
glucose levels exceed 10 mmol/L.

5 OTHER SUPPORTIVE THERAPY OF SEVERE SEPSIS

5.1Blood product administration

● Give red blood cells when hemoglobin decreases to <7.0 g/dL
(<70 g/L) to target a hemoglobin concentration of 7.0–9.0 g/dL
in adults. A higher hemoglobin level may be required in special
circumstances (e.g., myocardial ischemia, severe hypoxemia,
acute hemorrhage, cyanotic heart disease, or lactic acidosis)
● Administer platelets when:
o Counts are <5,000/mm3 regardless of bleeding
o Counts are 5,000–30,000/mm3 /L) and there is
significant bleeding risk

62
 o Higher platelet counts (≥50, 000/mm3 are required for
surgery or invasive procedures
● Do not use
o Fresh frozen plasma to correct laboratory clotting
abnormalities unless there is bleeding or planned invasive
procedures
o Antithrombin therapy
o Bicarbonate therapy for the purpose of improving
hemodynamics or reducing vasopressor requirements
when treating hypoperfusion- induced lactic acideamia
with pH ≥7.15

5.2 Consider mechanical ventilation of sepsis-induced ALI/ARDS

5.2.1 Sedation, analgesia, and neuromuscular blockade in sepsis

● Sedation may be indicated in selected patients. Use sedation
protocols with a sedation goal for critically ill mechanically
ventilated patients

5.2.2 Deep vein thrombosis prophylaxis

● Use either low-dose unfractionated heparin (UFH) or low
molecular weight heparin
● Low molecular weight heparin (LMWH), unless
contraindicated
● Use a mechanical prophylactic device, such as compression
stockings or an intermittent compression device, when heparin
is contraindicated

5.2.3 Stress ulcer prophylaxis

● Provide stress ulcer prophylaxis using H2 blocker or proton
pump inhibitor. Benefits of prevention of upper
gastrointestinal bleed must be weighed against the potential
for development of ventilator-acquired pneumonia

5.2.4 Consideration for limitation of support

● Discuss advance care planning with patients and families.
Describe likely outcomes and set realistic expectations

____________

The Ministry of Health SRH Unit coordinated the development of these

Guidelines and Protocols in January 2016.

63
64
ANNEXES: ALGORITHMS FOR SELECTED CLINICAL
CONDITIONS.
Annex 1: Neonatal Resuscitation

Adapted from NeonResus: The Victorian Newborn Resuscitation Project

65
 Annex 2: ECLAMPSIA

DEFINITION: Convulsions during the second half of pregnancy, labour and the first few days post-
partum.
● Clear airway
● Prevent aspiration and injuries
● Magnesium Sulphate therapy (Follow protocol)
● Do not leave the patient alone

UNCONSCIOUS CONSCIOUS

Call for help

Place the mother on the left side
Ensure unobstructed breathing
Give oxygen by face mask

Insert I.V. cannula (large bore)

Treat the blood pressure if diastolic >110mmHg
(Follow Hydralazine protocol).

Catheterise bladder
Transfer mother to H.D.U (High Dependency Unit)

STABILISATION: (may take 4-8 hrs)

Criteria for stabilisation

Blood pressure <110mm Hg (Diastolic), Mean Arterial blood
Pressure < 125mm Hg
Urine output > 100cc in 4 hour (30ml/hr)
No fits
Stable Cardiorespiratory system

YES NO

Cervix favourable
Continue management in
Gestation > 32 weeks
HDU until stabilised

YES NO

Deliver Conservative treatment Deliver

Vacuum (see protocol for Vacuum
C/S PREMATURITY) C/S
66
 Annex 3: POST PARTUM HAEMORRHAGE
Definition: - Vaginal bleeding > 500mls or less but life-threatening after the birth

of the baby.

Take blood for Hb, Grouping, Cross- matching and Clotting

time
Set up I.V. fluids (Ringers Lactate/NaCL)
Nil by mouth

Is bleeding due to an ATONIC UTERUS?

YES NO
YES
Catheterise bladder Is placenta retained?
Rub up contractions and expel clots
Give Oxytocin 10 Units as a bolus. Syntometrine 1
Amp. IV (0.5mg ergot. +5 IU Oxytocin as an
alternative)
Monitor vital signs – T.P.R, BP and level of
consciousness Examine to exclude perineal, vaginal
and cervical tears

Prepare for EUA

Suture and repair If ruptured uterus
accordingly proceed with
laparatomy /repair
of uterus or
Catheterise bladder hysterectomy
Try to expel placenta by control cord traction
If it fails, do manual removal of placenta
Give Oxytocin OR Ergometrine 0.5mg I.V and
Is uterus still atonic? antibiotics IV

NO
Transfuse fresh whole
YYYESblood, if
YES necessary
Keep uterus contracted with I.V
➢ Call the most senior doctor available Syntocinon 20-40 units in the I.V
➢ Repeat injection Oxytocin OR Syntometrine fluids
1 Amp. (I.V) OR Misoprostol (4x 200mcg) Continue monitoring vital signs
PR
➢ Add 20-40 units Oxytocin to drip
➢ Do bimanual compression of uterus
➢ Continue monitoring
➢ Transfuse fresh whole blood if necessary

IF BLEEDING DOES NOT STOP DO HYSTERECTOMY

67
68
69