Managing Complications in Pregnancy and Childbirth:: A Guide For Midwives and Doctors

WHO/RHR/00.
7
Distr: General
Integrated Management Of Pregnancy And Childbirth
Managing Complications in
Pregnancy and Childbirth:
A guide for midwives and doctors
WHO UNFPA UNICEF World Bank
Department of Reproductive Health and Research

Integrated Management Of Pregnancy And Childbirth
Managing Complications in
Pregnancy and Childbirth:
A guide for midwives and doctors
~ Department of Reproductive Health and Research

Family and Community Health
World Health Organization, Geneva, 2003
WHO Library Cataloguing-in-Publication Data
Managing complications in pregnancy and childbirth : a guide for midwives

and doctors.
At head of title: Integrated Management of Pregnancy and Childbirth.
l.Pregnancy complications - diagnosis 2.Pregnancy complications -

therapy 3.Labor, Obstetric 4.Delivery, Obstetric 5.Manuals I.World
Health Organization.
ISBN 92 4 154587 9 (NLM classification: WQ 240)
© World Health Organization 2003
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Printed & bound in India

ACKNOWLEDGEMENTS
Major contributors: Matthews Mathai

Harshad Sanghvi
Richard J. Guidotti
Contributors: Fredrik Broekhuizen

Beverley Chalmers
Robert Johnson
Anne Foster-Rosales
Jeffrey M. Smith
Jelka Zupan
Editing: Melissa McCormick
Editing Assistance: Ann Blouse

David Bramley
Kathleen Hines
Georgeanna Murgatroyd
Elizabeth Oliveras
Artist: Mary J ane Orley
Cover design: Maire Nf Mhearain
Layout: Deborah Brigade
The special contribution of George Povey, whose original work inspired

the idea for this manual, is gratefully acknowledged.
Reviewers:
Sabaratnam Arulkumaran Monirlslam Zahida Qureshi
Ann Davenport Barbara Kinzie Allan Rosenfield
Michael Dobson Andre Lalonde Abdul Bari Saifuddin
Jean Emmanuel Jerker Liljestrand Willibrord Shasha
Susheela Engelbrecht Enriquito Lu Betty Sweet
Miguel Espinoza Florence Mirembe Paul Van Look
Petra ten Hoope-Bender Glen Mola Patrice White
This guide represents a common understanding between WHO, UNFPA,
UNICEF, and the World Bank of key elements of an approach to reducing
maternal and perinatal mortality and morbidity. These agencies co-operate
closely in efforts to reduce maternal and perinatal mortality and morbidity.
The principles and policies of each agency are governed by the relevant
decisions of each agency's governing body and each agency implements the
interventions described in this document in accordance with these principles
and policies and within the scope of its mandate.
The guide has also been reviewed and endorsed by the International
Confederation of Midwives and the International Federation of Gynecology
and Obstetrics.
International Federation of
Gynecology and Obstetrics
The financial support towards the preparation and production of this

document, provided by the Governments of Australia, the Netherlands,
Sweden, the United Kingdom of Great Britain and Northern Ireland, and the
United States of America is gratefully acknowledged.
WHO gratefully acknowledges the technical and editorial assistance

provided by staff of JHPIEGO's Training in Reproductive Health and
Maternal and Neonatal Health Programs. Financial support was provided
by the Office of Population, Bureau for Global Health, United States
Agency for International Development (USAID) under the terms of Award
No. HRN-A-00-98-00041-00 and the Office of Health, Infectious Diseases
and Nutrition, Bureau for Global Health, USAID, under the terms of Award
No. HRN-A-00-98-00043-00. The opinions expressed herein are those of
the author[s) and do not necessarily reflect the views of the U.S. Agency for
International Development.
JHPIEG® An affiliate of
Johns Hopkins University
TABLE OF CONTENTS
Preface to the second printing iii

Preface V
Introduction vii
How to use the manual ix
Abbreviations xi '?
List of diagnoses xiii .?
I
SECTION 1: CLINICAL PRINCIPLES
Rapid initial assessment C-1

Talking with women and their families C-5
Emotional and psychological support C-7
Emergencies C-15
General care principles C-17
Clinical use of blood, blood products and replacement fluids C-23
Antibiotic therapy C-35
Anaesthesia and analgesia C-37
Operative care principles C-47
N ormallabour and childbirth C-57
Newborn care principles C-77
Provider and community linkages C-79
SECTION 2: SYMPTOMS
Shock S-1
Vaginal bleeding in early pregnancy S-7
Vaginal bleeding in later pregnancy and labour S-17
Vaginal bleeding after childbirth S-25
Elevated blood pressure, headache, blurred vision, convulsions or
loss of consciousness S-35
Unsatisfactory progress of labour S-57
Malpositions and malpresentations S-69
Shoulder dystocia S-83
Labour with an overdistended uterus S-87
Labour with a scarred uterus S-93
Fetal distress in labour S-95
Prolapsed cord S-97
Fever during pregnancy and labour S-99
Fever after childbirth S-107
Abdominal pain in early pregnancy S-115
Abdominal pain in later pregnancy and after childbirth S-119
Difficulty in breathing S-125
Loss of fetal movements S-131
ii Table of contents
Prelabour rupture of membranes S-135

Immediate newborn conditions or problems S-141
SECTION 3: PROCEDURES
Paracervical block P-1

Pudendal block P-3
Local anaesthesia for caesarean section P-7
Spinal (subarachnoid) anaesthesia P-11
Ketarnine P-13
External version P-15
Induction and augmentation of labour P-17
Vacuum extraction P-27
Forceps delivery P-33
Breech delivery P-37
Caesarean section P-43
Symphysiotomy P-53
Craniotomy and craniocentesis P-57
Dilatation and curettage P-61
Manual vacuum aspiration P-65
Culdocentesis and colpotomy P-69
Episiotomy P-71
Manual removal of placenta P-77
Repair of cervical tears P-81
Repair of vaginal and perineal tears P-83
Correcting uterine inversion P-91
Repair of ruptured uterus P-95
Uterine and utero-ovarian artery ligation P-99
Postpartum hysterectomy P-103
Salpingectomy for ectopic pregnancy P-109
SECTION 4: APPENDIX
Essential drugs for managing complications in pregnancy and

childbirth A-1
Index A-3
PREFACE TO THE SECOND PRINTING iii
The manual, Managing Complications in Pregnancy and Childbirth,

was officially launched at the Global Health Council conference
Healthy Women: Healthy World in Washington, DC in May 2001.
Since that time, the manual has been distributed to midwifery and
medical schools, individuals and programmes in over 40 countries
through the joint efforts of many organizations, including the World
Health Organization, International Federation of Gynecology and
Obstetrics, and the Maternal and Neonatal Health Program. The manual
has also been translated into French, Laotian, Mandarin, Mongolian, .
Spanish and Vietnamese.
Due to the immediate and overwhelming need for additional copies of
the manual, a second printing was necessary. Based on feedback from
individuals and groups around the world, minor revisions, including
clarification of wording and corrections (e.g. grammatical and
typographical), have been made, and some figures have been slightly
modified to make their meaning more clear. The manual will undergo
more extensive revision for a second edition, based on new evidence
and feedback from the field, in the future.
The first printing of the manual has proved to be hugely popular, so
much so that it has already been translated into French, Spanish and
Russian. Arabic and Chinese versions are also in preparation. The
manual is available also on WHO's web site:
www. who.int/reproducti ve-health
A number of countries and professional organizations have adapted the
manual to suit their own situations and this should improve the quality
of care in a great number of services all over the world.
Users are encouraged to send comments and remarks to
Dr Luc de Bernis
Department of Reproductive Health and Research
World Health Organization
Geneva
Switzerland
iv Preface to the second printing
PREFACE V
In support of the Safe Motherhood Initiative, the WHO Making

Pregnancy Safer Strategy focuses on the Health Sector's contribution to
reducing maternal and newborn deaths.
The Integrated Management of Pregnancy and Childbirth (IMPAC) is
the technical component of the aforementioned strategy and mainly
addresses the following:
Improving the skills of health workers through locally adapted
guidelines and standards for the management of pregnancy and
childbirth at different levels of the health care system;
Interventions to improve the health care system's response to the
needs of pregnant women and their newborns, and to improve the
district level management of health services, including the
provision of adequate staffing, logistics, supplies and equipment;
Health education and promotion of activities that improve family
and community attitudes and practices in relation to pregnancy and
childbirth.
This manual, and a similar one on the management of preterm and sick
newborns, is written for midwives and doctors working in district
hospitals. This manual complements and is consistent with the Essential
Care Practice Guide for Pregnancy and Childbirth which is prepared
mainly for the primary health care level. Together these manuals will
provide guidance for health workers who are responsible for the care of
pregnant women and newborns at all levels of care.
The interventions described in these manuals are based on the latest
available scientific evidence. Given that evidence-based medicine is the
standard on which to base clinical practice, it is planned to update the
manual as new information is acquired.
It is hoped that this manual will be used at the side of the patient, and
be readily available whenever a midwife or doctor is confronted with an
obstetric emergency.
vi Preface
INTRODUCTION vii
While most pregnancies and births are uneventful, all pregnancies are at
risk. Around 15% of all pregnant women develop a potentially
life-threatening complication that calls for skilled care and some will
require a major obstetrical intervention to survive. This manual is
written for midwives and doctors at the district hospital who are
responsible for the care of women with complications of pregnancy,
childbirth or the immediate postpartum period, including immediate
problems of the newborn.
In addition to the care midwives and doctors provide women in
facilities, they also have a unique role and relationship with:
the community of health care providers within the district health
system, including auxiliary and multipurpose health workers;
• family members of patients;
community leaders;
• populations with special needs (e.g. adolescents, women with
HIV/AIDS).
Midwives and doctors:
support activites for the improvement of all district health services;
strive for efficient and reliable referral systems;
• monitor the quality of health care services;
advocate for community participation in health related matters.
A district hospital is defined as a facility that is capable of providing
quality services, including operative delivery and blood transfusion.
Although many of the procedures in this manual require specialized
equipment and the expertise of specially trained providers, it should be
noted that many of the life-saving procedures described can also be
performed at health centres.
viii Introduction
HOW TO USE THE MANUAL ix
A woman presenting with a life-threatening obstetric complication is in

an emergency situation requiring immediate diagnosis and
management. Therefore, the main text of the manual is arranged by
symptom (e.g. vaginal bleeding in early pregnancy). Because this
symptom-based approach is different than most medical texts which are
arranged by disease, a list of diagnoses with the page number of the
corresponding diagnosis table is provided.
The emphasis of the manual is on rapid assessment and decision
making. The clinical action steps are based on clinical assessment with
limited reliance on laboratory or other tests and most are possible in a
variety of cl1nical settings (e.g. district hospital or health centre).
Section 1 outlines the clinical principles of managing complications in

pregnancy and childbirth and begins with a table that the health care
worker can use to rapidly assess the woman's condition and initiate
appropriate treatment. This section includes the general principles of
emergency, general and operative care, including infection prevention,
the use of blood and replacement fluids, antibiotics and anaesthesia and
analgesia. A description of normal labour and childbirth, including use
of the partograph and active management of the third stage, is included
in this section in order to provide the health care worker the
information needed to differentiate between the normal process and a
complication. Guidance on the initial care of the normal newborn is
also provided. Section 1 also includes information on providing
emotional support to the woman and her family and outlines the linkage
between the providers and their community.
Section 2 describes the symptoms by which women with complications
of pregnancy and childbirth present. The symptoms reflect the major
causes of mortality and morbidity. For each symptom there is a
statement of general, initial management. Diagnosis tables then lead to
identifying the diagnosis which is causing the symptom. Simplified
management protocols for these specific diagnoses then follow. Where
there are several choices of therapy, the most effective and inexpensive
is chosen. Also in this section is information on management for
immediate (within the first 24 hours) conditions or problems of the
newborn.
Section 3 describes the procedures that may be necessary in the
management of the condition. These procedures are not intended to be
detailed "how-to" instructions but rather a summary of the main steps
associated with each procedure. Because general operative care
principles are summarized in Section 1, these are not repeated for each
procedure, unless there is care required specific to the procedure (e.g.
X How to use the manual
post-procedure care for ketamine anaesthesia). Clear guidance is

provided on drugs and dosages, a wide variety of anaesthesia options
(e.g. safe caesarean section under local anaesthesia) and safe, effective
and lower cost techniques (e.g. single layer closure of the uterus).
Section 4 contains a list of essential drugs and an index. The index is
organized so that it can be used in an emergency situation to find
relevant material quickly. The most critical information including
diagnosis, management and steps for a procedure are listed first in bold.
Other relevant entries follow in alphabetical order. Only the pages
containing critical or relevant information are included, rather than
listing every page that contains the word or phrase.
ABBREVIATIONS xi
AIDS Acquired immunodeficiency syndrome

APH Antepartum haemorrhage
BP Blood pressure
HIV Human immunodeficiency virus
IM Intramuscular
lP Infection prevention
IUD Intrauterine device
IV Intravenous
PID Pelvic inflammatory disease
PPH Postpartum haemorrhage
STI Sexually transmitted infection
dL decilitre
g gram
kg kilogram
L litre
mcg micro gram
mg milligram
mL millilitre
xii Abbreviations
LIST OF DIAGNOSES xiii
Normal labour and childbirth C-57 Multiple pregnancy S-87

Shock S-1 Obstructed labour S-57
Occiput posterior position S-72
Abnormal fetal heart rate S-95 Occiput transverse position S-72
Abortion S-8 Ovarian cysts S-116
Abruptio placentae S-18 Pelvic abscess S-108
Acute pyelonephritis S-100 Peritonitis S-108
Amnionitis S-136 Placenta praevia S-18
Anaemia, severe S-126 Pneumonia S-126
Appendicitis S-116 Pre-eclampsia, mild or
Atonic uterus S-27 severe S-38
Breast infection S-108 Pregnancy-induced
Breast engorgement S-108 hypertension S-38
Breech presentation S-74 Prelabour rupture of
Bronchial asthma S-126 membranes S-136
Brow presentation S-73 Preterm labour S-120
Cephalopelvic disproportion S-57 Prolapsed cord S-97
Chronic hypertension S-38 Prolonged latent phase S-57
Coagulopathy S-19 Prolonged expulsive phase S-57
Compound presentation S-74 Retained placenta or
Cystitis S-100 placental fragments S-27
Eclampsia S-38 Ruptured uterus S-18
Ectopic pregnancy S-8 Scarred uterus S-93
Encephalitis S-39 Shoulder presentation S-75
Epilepsy S-39 Shoulder dystocia S-83
Excess amniotic fluid S-87 Tears of cervix and vagina S-27
Face presentation S-73 Tetanus S-38
False labour S-57 Transverse lie S-75
Fetal death S-132
Haemorrhage, antepartum S-17
Haemorrhage, postpartum S-27
Heart failure S-126
Inadequate uterine activity S-57
Infection of wounds S-108
Inverted uterus S-27
Large fetus S-87
Malaria, severe/complicated S-39
Malaria, uncomplicated S-100
Meconium S-95
Meningitis S-39
Metritis S-108
Migraine S-39
Molar pregnancy S-8
xiv List of diagnoses
SECTION 1
CLINICAL PRINCIPLES
RAPID INITIAL ASSESSMENT C-1
When a woman of childbearing age presents with a problem, rapidly
assess her condition to determine her degree of illness.
TABLE C-1 Rapid initial assessment"

Assess Danger Signs Consider
Airway and LOOK FOR: • severe anaemia
breathing • cyanosis (blueness) • heart failure
• respiratory distress • pneumonia
EXAMINE: • asthma
• skin: pallor See Difficulty in
• lungs: wheezing or rales breathing, page S-125
Circulation EXAMINE: Shock, page S-1
(signs of • skin: cool and clammy
shock) • pulse: fast (110 or more) and
weak
• blood pressure: low (systolic less
than 90 mm Hg)
Vaginal ASK IF: • abortion
bleeding • pregnant, length of gestation • ectopic pregnancy
(early or late • recently given birth • molar pregnancy
pregnancy or • placenta delivered See Vaginal bleeding in
after childbirth) EXAMINE: early pregnancy, page S-7
• vulva: amount of bleeding,
placenta retained, obvious tears • abruptio placentae
• uterus: atony • ruptured uterus
• bladder: full • placenta praevia
See Vaginal bleeding in
DO NOT DO A VAGINAL later pregnancy and
EXAM AT THIS STAGE labour, page S-17
• atonic uterus
• tears of cervix and vagina
• retained placenta
• inverted uterus
See Vaginal bleeding after
childbirth, page S-25
Unconscious ASK IF: • eclampsia
or convulsing • pregnant, length of gestation • malaria
EXAMINE: • epilepsy
• blood pressure: high (diastolic 90 • tetanus
mm Hg or more) See Convulsions or loss of
• temperature: 38°C or more consciousness, page S-35
a This list does not include all the possible problems a woman may face in
pregnancy or the puerperal period. It is meant to identify those problems that put the
woman at greater risk of maternal morbidity and mortality.
C-2 Rapid initial assessment
TABLE C-1 Cont. Rapid initial assessment
Assess Danger Signs Consider

Dangerous ASK IF: • urinary tract infection
fever • weak, lethargic • malaria
• frequent, painful urination See Fever during
EXAMINE: pregnancy and labour,
• temperature: 38°C or more page S-99
• unconscious
neck: stiffness • metritis
• lungs: shallow breathing, • pelvic abscess
consolidation • peritonitis
• abdomen: severe tenderness • breast infection
• vulva: purulent discharge See Fever after childbirth,
• breasts: tender page S-107
• complications of abortion
See Vaginal bleeding in
early pregnancy, page S-7
• pneumonia
See Difficulty in
breathing, page S-125
Abdominal ASK IF: • ovarian cyst
pain • pregnant, length of gestation • appendicitis
EXAMINE: • ectopic pregnancy
• blood pressure: low (systolic less See Abdominal pain in
than 90 mm Hg) early pregnancy, page
• pulse: fast (110 or more) S-115
• temperature: 38°C or more
• uterus: state of pregnancy • possible term or preterm
labour
• amnionitis
• abruptio placentae
• ruptured uterus
See Abdominal pain in
later pregnancy and after
childbirth, page S-119
The woman also needs prompt attention if she has any of the
following signs:
blood-stained mucus discharge (show) with palpable contractions;
ruptured membranes;
pallor;
Rapid initial assessment C-3
weakness;
fainting;
severe headaches;
blurred vision;
vomiting;
fever;
respiratory distress.
Send the woman to the front of the queue and treat promptly.
IMPLEMENTING A RAPID INITIAL ASSESSMENT SCHEME

Rapid initiation of treatment requires immediate recognition of the
specific problem and quick action. This can be done by:
training all staff-including clerks, guards, door-keepers or
switchboard operators-to react in an agreed upon fashion ("sound
the alarm," call for help) when a woman arrives at the facility with
an obstetric emergency or pregnancy complication or when the
facility is notified that a woman is being referred;
conducting clinical or emergency drills with staff to ensure their
readiness at all levels;
ensuring that access is not blocked (keys are available) and
equipment is in working order (daily checks) and staff are properly
trained to use it;
having norms and protocols (and knowing how to use them) to
recognize a genuine emergency and knowing how to react
immediately;
• clearly identifying which women in the waiting room-even those
waiting for routine consultations-warrant prompt or immediate
attention from the health worker and should therefore pass to the
front of the queue (agreeing that women in labour or pregnant
women who have any of the problems noted in Table C-1 should
immediately be seen by a health worker);
• agreeing on schemes by which women with emergencies can be
exempted from payment, at least temporarily (local insurance
schemes, health committee emergency funds).
C-4 Rapid initial assessment
TALKING WITH WOMEN AND THEIR FAMILIES c-s
Pregnancy is typically a time of joy and anticipation. It can also be a
time of anxiety and concern. Talking effectively with a woman and her
family can help build the woman's trust and confidence in her health
care providers.
Women who develop complications may have difficulty talking to the
provider and explaining their problem. It is the responsibility of the
entire health care team to speak with the woman respectfully and put
her at ease. Focusing on the woman means that the health care provider
and staff:
respect the woman's dignity and right to privacy;
are sensitive and responsive to the woman's needs;
are non-judgmental about the decisions that the woman and her
family have made thus far regarding her care.
It is understandable to disagree with a woman's risky behaviour or a
decision which has resulted in a delay in seeking care. It is not
acceptable, however, to show disrespect for a woman or disregard for a
medical condition that is a result of her behaviour. Provide corrective
counselling after the complication has been dealt with, not before or
during management of the problem.
RIGHTS OF WOMEN
Providers should be aware of the rights of women when receiving
maternity care services:
Every woman receiving care has a right to information about her
health.
Every woman has the right to discuss her concerns in an
environment in which she feels confident.
A woman should know in advance the type of procedure that is
going to be performed.
A woman (or her family, if necessary) should give informed
consent before the provider performs any procedure.
Procedures should be conducted in an environment (e.g. labour
ward) in which the woman's right to privacy is respected.
A woman should be made to feel as comfortable as possible when
receiving services.
C-6 Talking with women and their families
The woman has a right to express her views about the service she
receives.
When a provider talks to a woman about her pregnancy or a
complication, s/he should use basic communication techniques. These
techniques help the provider establish an honest, caring and trusting
relationship with the woman. If a woman trusts the provider and feels
that s/he has the best interests of the woman at heart, she will be more
likely to return to the facility for delivery or come early if there is a
complication.
COMMUNICATION TECHNIQUES
Speak in a calm, quiet manner and assure the woman that the
conversation is confidential. Be sensitive to any cultural or religious
considerations and respect her views. In addition:
Encourage the woman and her family to speak honestly and
completely about events surrounding the complication.
Listen to what the woman and her family have to say and
encourage them to express their concerns; try not to interrupt.
Respect the woman's sense of privacy and modesty by closing the
door or drawing curtains around the examination table.
Let the woman know that she is being listened to and understood.
Use supportive nonverbal communication such as nodding and
smiling.
Answer the woman's questions directly in a calm, reassuring
manner.
Explain what steps will be taken to manage the situation or
complication.
Ask the woman to repeat back to you the key points to assure her
understanding.
If a woman must undergo a surgical procedure, explain to her the
nature of the procedure and its risks and help to reduce her anxiety.
Women who are extremely anxious have a more difficult time during
surgery and recovery.
For more information on providing emotional support during an
emergency, see page C-7.
EMOTIONAL AND PSYCHOLOGICAL SUPPORT c-1
Emergency situations are often very disturbing for all concerned and
evoke a range of emotions that can have significant consequences.
EMOTIONAL AND PSYCHOLOGICAL REACTIONS

How each member of the family reacts to an emergency situation
depends on the:
marital status of the woman and her relationship with her partner;
social situation of the woman/couple and their cultural and
religious practices, beliefs and expectations;
personalities of the people involved and the quality and nature of
social, practical and emotional support;
nature, gravity and prognosis of the problem and the av11ilability
and quality of the health care services.
Common reactions to obstetric emergencies or death include:
denial (feelings of "it can't be true");
guilt regarding possible responsibility;
anger (frequently directed towards health care staff but often
masking anger that parents direct at themselves for "failure");
bargaining (particularly if the patient hovers for a while between
life and death);
depression and loss of self-esteem, which may be long-lasting;
isolation (feelings of being different or separate from others),
which may be reinforced by care givers who may avoid people
who experience loss;
disorientation.
GENERAL PRINCIPLES OF COMMUNICATION AND SUPPORT

While each emergency situation is unique, the following general
principles offer guidance. Communication and genuine empathy are
probably the most important keys to effective care in such situations.
C-8 Emotional and psychological support
AT THE TIME OF THE EVENT

Listen to those who are distressed. The woman/family will need to
discuss their hurt and sorrow.
Do not change the subject and move on to easier or less painful
topics of conversation. Show empathy.
Tell the woman/family as much as you can about what is
happening. Understanding the situation and its management can
reduce their anxiety and prepare them for what happens next.
Be honest. Do not hesitate to admit what you do not know.
Maintaining trust matters more than appearing knowledgeable.
If language is a barrier to communication, find a translator.
Do not pass the problem on to nursing staff or junior doctors.
Ensure that the woman has a companion of her choice and, where
possible, the same care giver throughout labour and delivery.
Supportive companionship can enable a woman to face fear and
pain, while reducing loneliness and distress.
Where possible, encourage companions to take an active role in
care. Position the companion at the top of the bed to allow the
companion to focus on caring for the woman's emotional needs.
Both during and after the event, provide as much privacy as
possible for the woman and her family.
AFTER THE EVENT

Give practical assistance, information and emotional support.
Respect traditional beliefs and customs and accommodate the
family's needs as far as possible.
Provide counselling for the woman/family and allow for reflection
on the event.
Explain the problem to help reduce anxiety and guilt. Many
women/families blame themselves for what has happened.
Listen and express understanding and acceptance of the woman's
feelings. Nonverbal communication may speak louder than words:
a squeeze of the hand or a look of concern can say an enormous
amount.
Repeat information several times and give written information, if

possible. People experiencing an emergency will not remember
much of what is said to them.
Health care providers may feel anger, guilt, sorrow, pain and
frustration in the face of obstetric emergencies that may lead them
to avoid the woman/family. Showing emotion is not a weakness.
Remember to care for staff who themselves may experience guilt,
grief, confusion and other emotions.
MATERNAL MORTALITY AND MORBIDITY
MATERNAL MORTALITY
Death of a woman in childbirth or from pregnancy-related events is a
devastating experience for the family and for surviving children. In
addition to the principles listed above, remember the following:

Provide psychological care as long as the woman is awake or even
vaguely aware of what is or might be happening to her.
If death is inevitable, provide emotional and spiritual comfort
rather than focusing on the emergency (now futile) medical care.
Provide dignity and respectful treatment at all times, even if the
woman is unconscious or has already died.
AFTER THE EVENT

Allow the woman's partner or family to be with her.
Facilitate the family's arrangements for the funeral, if possible, and
see that they have all the necessary documents.
• Explain what happened and answer any questions. Offer the
opportunity for the family to return to ask additional questions.
SEVERE MATERNAL MORBIDITY

Childbirth sometimes leaves a woman with severe physical or
psychological damage.

Include the woman and her family in the proceedings of the
delivery if possible, particularly if this is culturally appropriate.
Ensure that a staff member cares for the emotional and
informational needs of the woman and her partner, if possible.
AFTER THE EVENT

Clearly explain the condition and its treatment so that it is
understood by the woman and her companions.
Arrange for treatment and/or referral, when indicated.
Schedule a follow-up visit to check on progress and discuss
available options.
NEONATAL MORTALITY OR MORBIDITY·

While general principles of emotional support for women experiencing
obstetrical emergencies apply, when a baby dies or is born with an
abnormality some specific factors should be considered.
INTRAUTERINE DEATH OR STILLBIRTH

Many factors will influence the woman's reaction to the death of her
baby. These include those mentioned above as well as:
the woman's previous obstetric and life history;
the extent to which the baby was "wanted";
the events surrounding the birth and the cause of the loss;
previous experiences with death.

A void using sedation to help the woman cope. Sedation may delay
acceptance of the death and may make reliving the experience
later-part of the process of emotional healing-more difficult.
Allow the parents to see the efforts made by the care givers to
revive their baby.
• Encourage the woman/couple to see and hold the baby to facilitate
grieving.
Prepare the parents for the possibly disturbing or unexpected

appearance of the baby (red, wrinkled, peeling skin). If necessary,
wrap the baby so that it looks as normal as possible at first glance.
A void separating the woman and baby too soon (before she
indicates she is ready), as this can interfere with and delay the
grieving process.
AFTER THE EVENT

Allow the woman/family to continue to spend time with the baby.
Parents of a stillborn still need to get to know their baby.
People grieve in different ways, but for many remembrance is
important. Offer the woman/family small mementos such as a lock
of hair, a cot label or a name tag.
• Where it is the custom to name babies at birth, encourage the
woman/family to call the baby by the name they have chosen.
Allow the woman/family to prepare the baby for the funeral if they
wish.
Encourage locally-accepted burial practices and ensure that
medical procedures (such as autopsies) do not preclude them.
Arrange a discussion with both the woman and her partner to
discuss the event and possible preventive measures for the future.
DESTRUCTIVE OPERATIONS
Craniotomy or other destructive operations on the dead fetus may be
distressing and call for additional psychosocial care.

It is crucial that you explain to the mother and her family that the
baby is dead and that the priority is to save the mother.
Encourage the partner to provide support and comfort for the
mother until she is anaesthetized or sedated.
If the mother is awake or partially awake during the procedure,
protect her from visual exposure to the procedure and to the baby.
After the intervention, make arrangements so the baby can be seen
and/or held by the woman/family if they wish, especially if the
family is going to take care of the burial.
AFTER THE EVENT

Allow unlimited visiting time for the woman's companion.
Counsel the mother and her companion and reassure them that an
alternative was not available.
Arrange a follow-up visit several weeks after the event to answer
any questions and to prepare the woman for a subsequent
pregnancy (or the inability/inadvisability of another pregnancy).
Family planning should be provided, if appropriate (Table S-3,
page S-13).
BIRTH OF A BABY WITH AN ABNORMALITY

The birth of a baby with a malformation is a devastating experience for
the parents and family. Reactions may vary.
Allow the woman to see and hold the baby. Some women accept
their baby immediately while others may take longer.
Disbelief, denial and sadness are normal reactions, especially if the
abnormality is unpredicted. Feelings of unfairness, despair,
depression, anxiety, anger, failure and apprehension are common.

Give the baby to the parents at delivery. Allowing the parents to
see the problem immediately may be less traumatic.
In cases of severe deformity, wrap the baby before giving to the
mother to hold so that she can see the normality of the baby first.
Do not force the mother to examine the abnormality.
Provide a bed or cot in the room so the companion can stay with
the woman if she chooses.
AFTER THE EVENT

Discuss the baby and the problem with the woman and her family
together, if possible.
Allow the woman and her partner free access to their baby. Keep
the baby with the mother at all times. The more the woman and her
partner can do for the baby themselves, the more quickly they will
accept the baby as their own.
Ensure access to supportive professional individuals and groups.
PSYCHOLOGICAL MORBIDITY
Postpartum emotional distress is fairly common after pregnancy and
ranges from mild postpartum blues (affecting about 80% of women), to
postpartum depression or psychosis. Postpartum psychosis can pose a
threat to the life of the mother or baby.
POSTPARTUM DEPRESSION
Postpartum depression affects up to 34% of women and typically
occurs in the early postpartum weeks or months and may persist for a
year or more. Depression is not necessarily one of the leading
symptoms although it is usually evident. Other symptoms include
exhaustion, irritability, weepiness, low energy and motivational levels,
feelings of helplessness and hopelessness, loss of libido and appetite
and sleep disturbances. Headache, asthma, backache, vaginal discharge
and abdominal pain may be reported. Symptoms may include
obsessional thinking, fear of harming the baby or self, suicidal thoughts
and depersonalization.
The prognosis for postpartum depression is good with early diagnosis
and treatment. More than two-thirds of women recover within a year.
Providing a companion during labour may prevent postpartum
depression.
Once established, postpartum depression requires psychological
counselling and practical assistance. In general:
Provide psychological support and practical help (with the baby
and with home care).
Listen to the woman and provide encouragement and support.
Assure the woman that the experience is fairly common and that
many other women experience the same thing.
• Assist the mother to rethink the image of motherhood and assist the
couple to think through their respective roles as new parents. They
may need to adjust their expectations and activities.
If depression is severe, consider antidepressant drugs, if available.
Be aware that medication can be passed through breastmilk and
that breastfeeding should be reassessed.
Care can be home-based or can be offered through day-care clinics.
Local support groups of women who have had similar experiences are
most valuable.
POSTPARTUM PSYCHOSIS
Postpartum psychosis typically occurs around the time of delivery and
affects less than 1% of women. The cause is unknown, although about
half of the women experiencing psychosis also have a history of mental
illness. Postpartum psychosis is characterized by abrupt onset of
delusions or hallucinations, insomnia, a preoccupation with the baby,
severe depression, anxiety, despair and suicidal or infanticidal
impulses.
Care of the baby can sometimes continue as usual. Prognosis for
recovery is excellent but about 50% of women will suffer a relapse with
subsequent deliveries. In general:
Provide psychological support and practical help (with the baby as
well as with home care).
Listen to the woman and provide support and encouragement. This
is important for avoiding tragic outcomes.
Lessen stress.
• Avoid dealing with emotional issues when the mother is unstable.
If antipsychotic drugs are used, be aware that medication can be
passed through breastmilk and that breastfeeding should be
reassessed.
EMERGENCIES C-15
Emergencies can happen suddenly, as with a convulsion, or they can
develop as a result of a complication that is not properly managed or
monitored.
PREVENTING EMERGENCIES
Most emergencies can be prevented by:
careful planning;
following clinical guidelines;
close monitoring of the woman.
RESPONDING TO AN EMERGENCY
Responding to an emergency promptly and effectively requires that
members of the clinical team know their roles and how the team should
function to respond most effectively to emergencies. Team members
should also know:
clinical situations and their diagnoses and treatments;
drugs and their use, administration and side effects;
emergency equipment and how it functions.
The ability of a facility to deal with emergencies should be

assessed and reinforced by frequent practice emergency drills.
INITIAL MANAGEMENT
In managing an emergency:
Stay calm. Think logically and focus on the needs of the woman.
• Do not leave the woman unattended.
Take charge. Avoid confusion by having one person in charge.
SHOUT FOR HELP. Have one person go for help and have
another person gather emergency equipment and supplies (e.g.
oxygen cylinder, emergency kit).
If the woman is unconscious, assess the airway, breathing and
circulation.
C-16 Emergencies
If shock is suspected, immediately begin treatment (page S-1).

Even if signs of shock are not present, keep shock in mind as you
evaluate the woman further because her status may worsen rapidly.
If shock develops, it is important to begin treatment immediately.
Position the woman lying down on her left side with her feet
elevated. Loosen tight clothing.
• Talk to the woman and help her to stay calm. Ask what happened
and what symptoms she is experiencing.
Perform a quick examination including vital signs (blood pressure,
pulse, respiration, temperature) and skin colour. Estimate the
amount of blood lost and assess symptoms and signs.
GENERAL CARE PRINCIPLES C-17
INFECTION PREVENTION
Infection prevention (lP) has two primary objectives:
prevent major infections when providing services;
minimize the risk of transmitting serious diseases such as
hepatitis Band HIV/AIDS to the woman and to service
providers and staff, including cleaning and housekeeping
personnel.
The recommended lP practices are based on the following
principles:
Every person (patient or staff) must be considered potentially
infectious;
Hand washing is the most practical procedure for preventing
cross-contamination;
Wear gloves before touching anything wet-broken skin,
mucous membranes, blood or other body fluids (secretions or
excretions);
Use barriers (protective goggles, face masks or aprons) if
splashes and spills of any body fluids (secretions or
excretions) are anticipated;
Use safe work practices, such as not recapping or bending
needles, proper instrument processing and proper disposal of
medical waste.
HANDWASHING
Vigorously rub together all surfaces of the hands lathered with
plain or antimicrobial soap. Wash for 15-30 seconds and rinse with
a stream of running or poured water.
Wash hands:
before and after examining the woman (or having any direct
contact);
after exposure to blood or any body fluids (secretions or
excretions), even if gloves were worn;
after removing gloves because the gloves may have holes in
them.
C-18 General care principles
To encourage handwashing, programme managers should make

every effort to provide soap and a continuous supply of clean
water, either from the tap or a bucket, and single-use towels. Do
not use shared towels to dry hands.
To wash hands for surgical procedures, see page C-48.
GLOVES AND GOWNS

Wear gloves:
when performing a procedure (Table C-2, page C-19);
when handling soiled instruments, gloves and other items;
when disposing of contaminated waste items (cotton, gauze or
dressings).
A separate pair of gloves must be used for each woman to avoid
cross-contamination.
Disposable gloves are preferred, but where resources are limited,
surgical gloves can be reused if they are:
decontaminated by soaking in 0.5% chlorine solution for 10
minutes;
washed and rinsed;
sterilized by autoclaving (eliminates all microorganisms) or
high-level disinfected by steaming or boiling (eliminates all
microorganisms except some bacterial endospores).
Note: If single-use disposable surgical gloves are reused, they
should not be processed more than three times because invisible
tears may occur.
Do not use gloves that are cracked, peeling or have detectable

holes or tears.
A clean, but not necessarily sterile, gown should be worn during all
delivery procedures:
If the gown has long sleeves, the gloves should be put over the
gown sleeve to avoid contamination of the gloves;
Ensure that gloved hands (high-level disinfected or sterile) are
held above the level of the waist and do not come into contact
with the gown.
TABLE C-2 Glove and gown requirements for common obstetric

procedures
Procedure Preferred Alternative Gown

Gloves• Glovesb
Blood drawing, starting Exam' High-level None
IV infusion disinfected
surgicald
Pelvic examination Exam High-level None
disinfected
surgical
Manual vacuum High-level Sterile surgical None
aspiration, dilatation and disinfected
curettage, colpotomy, surgical
culdocentesis
Laparotomy and intra- High-level Sterile surgical Clean, high-
abdominal procedures, disinfected level
artificial rupture of surgical disinfected or
membranes, delivery, sterile
instrumental delivery,
symphysiotomy,
episiotomy, repair of
cervical or perineal tears,
craniotomy,
craniocentesis, bimanual
compression of uterus,
manual removal of
placenta, correcting
uterine inversion
Handling and cleaning Utility< Exam or None
instruments surgical
Handling contaminated Utility Exam or None
waste surgical
Cleaning blood or body Utility Exam or None
fluid spills surgical
• Gloves and gowns are not required to be worn to check blood pressure or
temperature, or to give injections.
b Alternative gloves are generally more expensive and require more preparation than
preferred gloves.
' Exam gloves are single-use disposable latex gloves. If gloves are reusable, they
should be decontaminated, cleaned and either sterilized or high-level disinfected
before use.
d Surgical gloves are latex gloves that are sized to fit the hand.
e Utility gloves are thick household gloves.
HANDLING SHARP INSTRUMENTS AND NEEDLES

OPERATING THEATRE AND LABOUR WARD
Do not leave sharp instruments or needles ("sharps") in places
other than "safe zones" (page C-51).
Tell other workers before passing sharps.
HYPODERMIC NEEDLES AND SYRINGES

Use each needle and syringe only once.
Do not disassemble needle and syringe after use.
Do not recap, bend or break needles prior to disposal.
Dispose of needles and syringes in a puncture-proof container.
Make hypodermic needles unusable by burning them.
Note: Where disposable needles are not available and recapping is
practised, use the "one-handed" recap method:
Place the cap on a hard, flat surface;
Hold the syringe with one hand and use the needle to "scoop
up" the cap;
When the cap covers the needle completely, hold the base of
the needle and use the other hand to secure the cap.
WASTE DISPOSAL
The purpose of waste disposal is to:
prevent the spread of infection to hospital personnel who
handle the waste;
prevent the spread of infection to the local community;
protect those who handle waste from accidental injury.
Noncontaminated waste (e.g. paper from offices, boxes) poses no
infectious risk and can be disposed of according to local
guidelines.
Proper handling of contaminated waste (blood- or body fluid-
contaminated items) is required to minimize the spread of infection
to hospital personnel and the community. Proper handling means:
wearing utility gloves;
transporting solid contaminated waste to the disposal site in

covered containers;
disposing of all sharp items in puncture-proof containers;
carefully pouring liquid waste down a drain or flushable toilet;
burning or burying contaminated solid waste;
washing hands, gloves and containers after disposal of
infectious waste.
STARTING AN IV INFUSION
Start an IV infusion (two if the woman is in shock) using a large-
bore (16-gauge or largest available) cannula or needle.
Infuse IV fluids (normal saline or Ringer's lactate) at a rate
appropriate for the woman's condition.
Note: If the woman is in shock, avoid using plasma substitutes
(e.g. dextran). There is no evidence that plasma substitutes are
superior to normal saline in the resuscitation of a shocked woman
and dextran can be harmful in large doses.
If a peripheral vein cannot be cannulated, perform a venous cut-
down (Fig S-1, page S-3).
BASIC PRINCIPLES FOR PROCEDURES

Before any simple (nonoperative) procedure, it is necessary to:
Gather and prepare all supplies. Missing supplies can disrupt a
procedure.
Explain the procedure and the need for it to the woman and obtain
consent.
Provide adequate pain medication according to the extent of the
procedure planned. Estimate the length of time for the procedure
and provide pain medication accordingly (page C-37).
Place the patient in a position appropriate for the procedure being
performed. The most common position used for obstetric
procedures (e.g. manual vacuum aspiration) is the lithotomy
position (Fig C-1, page C-22).
FIGUREC-1 The lithotomy position
Wash hands with soap and water (page C-17) and put on gloves
appropriate for the procedure (Table C-2, page C-19).
If the vagina and cervix need to be prepared with an antiseptic
for the procedure (e.g. manual vacuum aspiration):
Wash the woman's lower abdomen and perineal area with
soap and water, if necessary;
Gently insert a high-level disinfected or sterile speculum or
retractor(s) into the vagina;
Apply antiseptic solution (e.g. iodophors, chlorhexidine) three
times to the vagina and cervix using a high-level disinfected or
sterile ring forceps and a cotton or gauze swab.
If the skin needs to be prepared with an antiseptic for the
procedure (e.g. symphysiotomy):
Wash the area with soap and water, if necessary;
Apply antiseptic solution (e.g. iodophors, chlorhexidine) three
times to the area using a high-level disinfected or sterile ring
forceps and a cotton or gauze swab. If the swab is held with a
gloved hand, do not contaminate the glove by touching
unprepared skin;
Begin at the centre of the area and work outward in a circular
motion away from the area;
At the edge of the sterile field discard the swab.
Never go back to the middle of the prepared area with the same
swab. Keep your arms and elbows high and surgical dress away
from the surgical field.
CLINICAL USE OF BLOOD, BLOOD PRODUCTS c-23
AND REPLACEMENT FLUIDS
Obstetric care may require blood transfusions. It is important to use
blood, blood products and replacement fluids appropriately and to be
aware of the principles designed to assist health workers in deciding
when (and when not) to transfuse.
The appropriate use of blood products is defined as the transfusion of
safe blood products to treat a condition leading to significant morbidity
or mortality that cannot be prevented or managed effectively by other
means.
Conditions that may require blood transfusion include:
• postpartum haemorrhage leading to shock;
loss of a large volume of blood at operative delivery;
severe anaemia, especially in later pregnancy or if accompanied by
cardiac failure.
Note: For anaemia in early pregnancy, treat the cause of anaemia
and provide haematinics.
District hospitals should be prepared for the urgent need for blood
transfusion. It is mandatory for obstetric units to keep stored blood
available, especially type 0 negative blood and fresh frozen plasma, as
these can be life-saving.
UNNECESSARY USE OF BLOOD PRODUCTS

Used correctly, blood transfusion can save lives and improve health. As
with any therapeutic intervention it may, however, result in acute or
delayed complications and it carries the risk of transmission of
infectious agents. It is also expensive and uses scarce resources.
Transfusion is often unnecessary because:
Conditions that may eventually require transfusion can often
be prevented by early treatment or prevention programmes;
Transfusions of whole blood, red cells or plasma are often
given to prepare a woman quickly for planned surgery, or to
allow earlier discharge from the hospital. Other treatments,
such as the infusion of IV fluids, are often cheaper, safer and
equally effective (page C-30).
C-24 Clinical use of blood, blood products and replacement fluids
Unnecessary transfusion can:

expose the woman to unnecessary risks;
cause a shortage of blood products for women in real need.
Blood is an expensive, scarce resource.
RISKS OF TRANSFUSION
Before prescribing blood or blood products for a woman, it is essential
to consider the risks of transfusing against the risks of not transfusing.
WHOLE BLOOD OR RED CELL TRANSFUSION

The transfusion of red cell products carries a risk of incompatible
transfusion and serious haemolytic transfusion reactions.
Blood products can transmit infectious agents-including HIV,
hepatitis B, hepatitis C, syphilis, malaria and Chagas disease-to
the recipient.
Any blood product can become bacterially contaminated and very
dangerous if it is manufactured or stored incorrectly.
PLASMA TRANSFUSION
Plasma can transmit most of the infections present in whole blood.
Plasma can also cause transfusion reactions.
There are very few clear indications for plasma transfusion (e.g.
coagulopathy) and the risks often outweigh any possible benefit.
BLOOD SAFETY
The risks associated with transfusion can be reduced by:
effective blood donor selection, deferral and exclusion;
screening for transfusion-transmissible infections in the blood
donor population (e.g. HIV/AIDS and hepatitis);
quality-assurance programmes;
high-quality blood grouping, compatibility testing, component
separation and storage and transportation of blood products;
appropriate clinical use of blood and blood products.
SCREENING FOR INFECTIOUS AGENTS

Every unit of donated blood should be screened for transfusion-
transmissible infections using the most appropriate and effective
tests, in accordance with both national policies and the prevalence
of infectious agents in the potential blood donor population.
All donated blood should be screened for the following:
HIV-1 and HIV-2;
Hepatitis B surface antigen (HBsAg);
Treponema pallidum antibody (syphilis).
Where possible, all donated blood should also be screened for:
Hepatitis C;
Chagas disease, in countries where the seroprevalence is
significant;
Malaria, in low-prevalence countries when donors have
travelled to malarial areas. In areas with a high prevalence of
malaria, blood transfusion should be accompanied by
prophylactic antimalarials.
No blood or blood product should be released for transfusion until
all nationally required tests are shown to be negative.
Perform compatibility tests on all blood components transfused
even if, in life-threatening emergencies, the tests are performed
after the blood products have been issued.
Blood that has not been obtained from appropriately selected

donors and that has not been screened for transfusion-
transmissible infectious agents (e.g. HIV, hepatitis), in
accordance with national requirements, should not be issued
for transfusion, other than in the most exceptional life-
threatening situations.
PRINCIPLES OF CLINICAL TRANSFUSION

The fundamental principle of the appropriate use of blood or blood
product is that transfusion is only one element of the woman's
management. When there is sudden rapid loss of blood due to
haemorrhage, surgery or complications of childbirth, the most urgent
need is usually the rapid replacement of the fluid lost from circulation.
Transfusion of red cells may also be vital to restore the oxygen-carrying

capacity of the blood.
Minimize "wastage" of a woman's blood (to reduce the need for
transfusion) by:
using replacement fluids for resuscitation;
minimizing the blood taken for laboratory use;
using the best anaesthetic and surgical techniques to minimize
blood loss during surgery;
salvaging and reinfusing surgical blood lost during procedures
(autotransfusion), where appropriate (page S-14).
Principles to remember:
Transfusion is only one element of managing a woman.
• Decisions about prescribing a transfusion should be based on
national guidelines on the clinical use of blood, taking the
woman's needs into account.
Blood loss should be minimized to reduce the woman's need for
transfusion.
The woman with acute blood loss should receive effective
resuscitation (IV replacement fluids, oxygen, etc.) while the need
for transfusion is being assessed.
The woman's haemoglobin value, although important, should not
be the sole deciding factor in starting the transfusion. The decision
to transfuse should be supported by the need to relieve clinical
signs and symptoms and prevent significant morbidity and
mortality.
The clinician should be aware of the risks of transfusion-
transmissible infection in blood products that are available.
Transfusion should be prescribed only when the benefits to the
woman are likely to outweigh the risks.
• A trained person should monitor the transfused woman and
respond immediately if any adverse effects occur (page C-27).
The clinician should record the reason for transfusion and
investigate any adverse effects (page C-28).
PRESCRIBING BLOOD
Prescribing decisions should be based on national guidelines on the
clinical use of blood, taking the woman's needs into account.
Before prescribing blood or blood products for a woman, keep in
mind the following:
expected improvement in the woman's clinical condition;
methods to minimize blood loss to reduce the woman's need
for transfusion;
alternative treatments that may be given, including IV
replacement fluids or oxygen, before making the decision to
transfuse;
specific clinical or laboratory indications for transfusion;
risks of transmitting HIV, hepatitis, syphilis or other infectious
agents through the blood products that are available;
benefits of transfusion versus risk for the particular woman;
other treatment options if blood is not available in time;
need for a trained person to monitor the woman and
immediately respond if a transfusion reaction occurs.
MONITORING THE TRANSFUSED WOMAN

For each unit of blood transfused, monitor the woman at the following
stages:
before starting the transfusion;
at the onset of the transfusion;
15 minutes after starting the transfusion;
at least every hour during the transfusion;
at four-hour intervals after completing the transfusion.
Closely monitor the woman during the first 15 minutes of the

transfusion and regularly thereafter to detect early symptoms
and signs of adverse effects.
At each of these stages, record the following information on the

woman's chart:
general appearance;
temperature;
pulse;
blood pressure;
respiration;
fluid balance (oral and IV fluid intake, urinary output).
In addition, record:
• the time the transfusion is started;
the time the transfusion is completed;
the volume and type of all products transfused;
the unique donation numbers of all products transfused;
any adverse effects.
RESPONDING TO A TRANSFUSION REACTION

Transfusion reactions may range from a minor skin rash to anaphylactic
shock. Stop the transfusion and keep the IV line open with IV fluids
(normal saline or Ringer's lactate) while making an initial assessment
of the acute transfusion reaction and seeking advice. If the reaction is
minor, give promethazine 10 mg by mouth and observe.
MANAGING ANAPHYLACTIC SHOCK FROM MISMATCHED BLOOD

TRANSFUSION
Manage as for shock (page S-1) and give:
adrenaline 1: 1000 solution (0.1 mL in 10 mL normal saline or
Ringer's lactate) IV slowly;
promethazine 10 mg IV;
hydrocortisone 1 g IV every two hours as needed.
• If bronchospasm occnrs, give aminophylline 250 mg in 10 mL
normal saline or Ringer's lactate IV slowly.
• Combine resuscitation measures above until stabilized.
• Monitor renal, pulmonary and cardiovascular functions.
Transfer to referral centre when stable.
DOCUMENTING A TRANSFUSION REACTION

Immediately after the reaction occurs, take the following samples
and send with a request form to the blood bank for laboratory
investigations.
immediate post-transfusion blood samples:
one clotted;
one anticoagulated (EDT A/sequestrene) taken from the
vein opposite the infusion site;
the blood unit and giving set containing red cell and plasma
residues from the transfused donor blood;
the first specimen of the woman's urine following the reaction.
If septic shock is suspected due to a contaminated blood unit,
take a blood culture in a special blood culture bottle.
Complete a transfusion reaction report form.
After the initial investigation of the transfusion reaction, send the
following to the blood bank for laboratory investigations:
blood samples at 12 hours and 24 hours after the start of the
reaction:
one clotted;
one anticoagulated (EDTA/sequestrene) taken from the
vein opposite the infusion site;
all urine for at least 24 hours after the start of the reaction.
Immediately report all acute transfusion reactions, with the
exception of mild skin rashes, to a medical officer and to the blood
bank that supplied the blood.
Record the following information on the woman's chart:
type of transfusion reaction;
length of time after the start of transfusion that the reaction
occurred;
volume and type of blood products transfused;
unique donation numbers of all products transfused.
REPLACEMENT FLUIDS: SIMPLE SUBSTITUTES FOR

TRANSFUSION
Only normal saline (sodium chloride 0.9%) or balanced salt solutions
that have a similar concentration of sodium to plasma are effective
replacement fluids. These should be available in all hospitals where IV
replacement fluids are used.
Replacement fluids are used to replace abnormal losses of blood,
plasma or other extracellular fluids by increasing the volume of the
vascular compartment. They are used principally in:
management of women with established hypovolaemia (e.g.
haemorrhagic shock);
maintenance of normovolaemia in women with on-going fluid
losses (e.g. surgical blood loss).
INTRAVENOUS REPLACEMENT THERAPY

Intravenous replacement fluids are first-line treatment for
hypovolaemia. Initial treatment with these fluids may be life-saving and
can provide some time to control bleeding and obtain blood for
transfusion if it becomes necessary.
CRYSTALLOID FLUIDS
Crystalloid replacement fluids:
contain a similar concentration of sodium to plasma;
cannot enter cells because the cell membrane is impermeable
to sodium;
pass from the vascular compartment to the extracellular space
(normally only a quarter of the volume of crystalloid infused
remains in the vascular compartment) compartment.
To restore circulating blood volume (intravascular volume), infuse
crystalloids in a volume at least three times the volume lost.
Dextrose (glucose) solutions are poor replacement fluids. Do

not use them to treat hypovolaemia unless there is no other
alternative.
COLLOID FLUIDS
Colloid solutions are composed of a suspension of particles that are
larger than crystalloids. Colloids tend to remain in the blood where
they mimic plasma proteins to maintain or raise the colloid osmotic
pressure of blood.
Colloids are usually given in a volume equal to the blood volume
lost. In many conditions where the capillary permeability is
increased (e.g. trauma, sepsis), leakage out of the circulation will
occur and additional infusions will be necessary to maintain blood
volume. ·
Points to remember:
There is no evidence that colloid solutions (albumin, dextrans,
gelatins, hydroxyethyl starch solutions) have advantages over
normal saline or balanced salt solutions for resuscitation.
There is evidence that colloid solutions may have an adverse effect
on survival.
• Colloid solutions are much more expensive than normal saline and
balanced salt solutions.
Human plasma should not be used as a replacement fluid. All
forms of plasma carry a similar risk as whole blood of transmitting
infection, such as HIV and hepatitis.
Plain water should never be infused intravenously. It will cause
haemolysis and will probably be fatal.
There is a very limited role for colloids in resuscitation.
SAFETY
Before giving any IV infusion:
check that the seal of the infusion bottle or bag is not broken;
check the expiry date;
check that the solution is clear and free from visible particles.
MAINTENANCE FLUID THERAPY

Maintenance fluids are crystalloid solutions, such as dextrose or
dextrose in normal saline, used to replace normal physiological losses
through skin, lungs, faeces and urine. If it is anticipated that the woman
will receive IV fluids for 48 hours or more, infuse a balanced

electrolyte solution (e.g. potassium chloride 1.5 gin 1 L IV fluids) with
dextrose. The volume of maintenance fluids required by a woman will
vary, particularly if the woman has fever or with high ambient
temperature or humidity, when losses will increase.
OTHER ROUTES OF FLUID ADMINISTRATION

There are other routes of fluid administration in addition to the IV
route.
ORAL AND NASOGASTRIC ADMINISTRATION
This route can often be used for women who are mildly
hypovolaemic and for women who can receive oral fluids.
Oral and nasogastric administration should not be used if:
the woman is severely hypovolaemic;
the woman is unconscious;
there are gastrointestinallesions or reduced gut motility (e.g.
obstruction);
imminent surgery with general anaesthesia is planned.
RECTAL ADMINISTRATION
Rectal administration of fluids is not suitable for severely
hypovolaemic women.
Advantages of rectal administration include:
It allows the ready absorption of fluids;
Absorption ceases and fluids are ejected when hydration is
complete;
It is administered through a plastic or rubber enema tube
inserted into the rectum and connected to a bag or bottle of
fluid;
The fluid rate can be controlled by using an IV set, if
necessary;
The fluids do not have to be sterile. A safe and effective
solution for rectal rehydration is 1 L of clean drinking water to
which a teaspoon of table salt is added.
SUBCUTANEOUS ADMINISTRATION
Subcutaneous administration can occasionally be used when other
routes of administration are unavailable, but this method is
unsuitable for severely hypovolaemic women.
• Sterile fluids are administered through a cannula or needle inserted
into the subcutaneous tissue (the abdominal wall is a preferred
site).
Solutions containing dextrose can cause tissue to die and

should not be given subcutaneously.
ANTIBIOTIC THERAPY C-35
Infection during pregnancy and the postpartum period may be caused

by a combination of organisms, including aerobic and anaerobic cocci
and bacilli. Antibiotics should be started based on observation of the
woman. If there is no clinical response, culture of uterine or vaginal
discharge, pus or urine may help in choosing other antibiotics. In
addition, blood culture may be done if septicaemia (bloodstream
invasion) is suspected.
Uterine infection can follow an abortion or childbirth and is a major
cause of maternal death. Broad spectrum antibiotics are often required
to treat these infections. In cases of unsafe abortion and non-
institutional delivery, anti-tetanus prophylaxis should also be provided
(Box S-5, pageS-51).
PROVIDING PROPHYLACTIC ANTIBIOTICS

Performing certain obstetrical procedures (e.g. caesarean section,
manual removal of placenta) increases a woman's risk of infectious
morbidity. This risk can be reduced by:
• following recommended infection prevention practices (page
C-17);
providing prophylactic antibiotics at the time of the procedure.
Prophylactic antibiotics are given to help prevent infection. If a woman
is suspected to have or is diagnosed as having an infection,
therapeutic antibiotics are more appropriate.
Give prophylactic antibiotics 30 minutes before the start of a procedure,
when possible, to allow adequate blood levels of the antibiotic at the
time of the procedure. An exception to this is caesarean section, for
which prophylactic antibiotics should be given when the cord is
clamped after delivery of the baby. One dose of prophylactic
antibiotics is sufficient and is no less effective than three doses or 24
hours of antibiotics in preventing infection. If the procedure lasts
longer than six hours or blood loss is 1500 mL or more, give a
second dose of prophylactic antibiotics to maintain adequate blood
levels during the procedure.
PROVIDING THERAPEUTIC ANTIBIOTICS

As a first defense against serious infections, give a combination of
antibiotics:
C-36 Antibiotic therapy
ampicillin 2 g IV every six hours;

PLUS gentamicin 5 mglkg body weight IV every 24 hours;
PLUS metronidazole 500 mg IV every eight hours.
Note: If the infection is not severe, amoxicillin 500 mg by mouth
every eight hours can be used instead of ampicillin. Metronidazole
can be given by mouth instead ofiV.
If the clinical response is poor after 48 hours, ensure adequate
dosages of antibiotics are being given, thoroughly re-evaluate the
woman for other sources of infection or consider altering treatment
according to reported microbial sensitivity (or adding an additional
agent to cover anaerobes, if not yet given).
If culture facilities are not available, re-examine for pus
collection, especially in the pelvis, and for non-infective causes
such as deep vein and pelvic vein thrombosis. Consider the
possibility of infection due to organisms resistant to the above
combination of antibiotics:
If staphylococcal infection is suspected, add:
cloxacillin 1 g IV every four hours;
OR vancomycin 1 g IV every 12 hours infused over one
hour;
If clostridial infection or Group A haemolytic streptococci
is suspected, add penicillin 2 million units IV every four
hours;
If neither of the above are possibilities, add ceftriaxone 2 g
IV every 24 hours.
Note: To avoid phlebitis, change the infusion site every three days
or at the first sign of inflammation.
If the infection does not clear, evaluate for the source of infection.
For the treatment of metritis, combinations of antibiotics are usually
continued until the woman is fever-free for 48 hours. Discontinue
antibiotics once the woman has been fever-free for 48 hours. There is
no need to continue with oral antibiotics, as this has not been proven to
have additional benefit. Women with blood-stream infections, however,
will require antibiotics for at least seven days.
ANAESTHESIA AND ANALGESIA C-37
Pain relief may be required during labour and is required during and
after operative procedures. Analgesic drugs and methods of support
during labour, local anaesthesia, general principles for using
anaesthesia and analgesia, and postoperative analgesia are discussed.
ANALGESIC DRUGS DURING LABOUR

The perception of pain varies greatly with the woman's emotional
state. Supportive care during labour provides reassurance and
decreases the perception of pain (page C-57).
If the woman is distressed by pain, allow her to walk around or
assume any comfortable position. Encourage her companion to
massage her back or sponge her face between contractions.
Encourage the use of breathing techniques and allow the woman to
take a warm bath or shower if she chooses. For most women, this
is enough to cope with the pain of labour. If necessary, give:
pethidine 1 mg/kg body weight (but not more than 100 mg) IM
or IV slowly every four hours as needed or give morphine 0.1
mg/kg body weight IM;
promethazine 25 mg IM or IV if vomiting occurs.
Barbiturates and sedatives should not be used to relieve

anxiety in labour.
DANGER
If pethidine or morphine is given to the mother, the baby may suffer
from respiratory depression. Naloxone is the antidote.
Note: Do not administer naloxone to newborns whose mothers are
suspected of having recently abused narcotic drugs.
If there are signs of respiratory depression in the newborn, begin
resuscitation immediately:
After vital signs have been established, give naloxone 0.1
mg/kg body weight IV to the newborn;
If the infant has adequate peripheral circulation after
successful resuscitation, naloxone can be given IM. Repeated
doses may be required to prevent recurrent respiratory
depression.
C-38 Anaesthesia and analgesia
If there are no signs of respiratory depression in the newborn, but

pethidine or morphine was given within four hours of delivery,
observe the baby expectantly for signs of respiratory depression
and treat as above if they occur.
PREMEDICATION WITH PROMETHAZINE AND DIAZEPAM

Premedication is required for procedures that last longer than 30
minutes. The dose must be adjusted to the weight and condition of the
woman and to the condition of the fetus (when present).
A popular combination is pethidine and diazepam:
Give pethidine 1 mg!k:g body weight (but not more than 100 mg)
IM or IV slowly or give morphine 0.1 mg/kg body weight IM.
• Give diazepam in increments of 1 mg IV and wait at least two
minutes before giving another increment. A safe and sufficient
level of sedation has been achieved when the woman's upper eye
lid droops and just covers the edge of the pupil. Monitor the
respiratory rate every minute. If the respiratory rate falls below
10 breaths per minute, stop administration of all sedative or
analgesic drugs.
Do not administer diazepam with pethidine in the same syringe, as

the mixture forms a precipitate. Use separate syringes.
LOCAL ANAESTHESIA
Local anaesthesia (lignocaine with or without adrenaline) is used to
infiltrate tissue and block the sensory nerves.
Because a woman with local anaesthesia remains awake and alert
during the procedure, it is especially important to ensure:
counselling to increase cooperation and minimize her fears;
good communication throughout the procedure as well as
physical reassurance from the provider, if necessary;
time and patience, as local anaesthetics do not take effect
immediately.
The following conditions are required for the safe use of local
anaesthesia:
All members of the operating team must be knowledgeable
and experienced in the use of local anaesthetics;
Emergency drugs and equipment (suction, oxygen,
resuscitation equipment) should be readily available and in
usable condition, and all members of the operating team
trained in their use.
LIGNOCAINE
Lignocaine preparations are usually 2% or 1% and require dilution
before use (Box C-1). For most obstetric procedures, the preparation is
diluted to 0.5%, which gives the maximum effect with the least
toxicity.
BOX C-1 Preparation of lignocaine 0.5% solution
Combine:
• lignocaine 2%, one part;
• normal saline or sterile distilled water, three parts (do not use glucose
solution as it increases the risk of infection).
or
• lignocaine 1%, one part;
• normal saline or sterile distilled water, one part.
ADRENALINE
Adrenaline causes local vasoconstriction. Its use with lignocaine has the
following advantages:
• less blood loss;
• longer effect of anaesthetic (usually one to two hours);
• less risk of toxicity because of slower absorption into the general
circulation.
If the procedure requires a small surface to be anaesthetized or
requires less than 40 mL of lignocaine, adrenaline is not necessary. For
larger surfaces, however, especially when more than 40 mL is needed,
adrenaline is required to reduce the absorption rate and thereby reduce
toxicity.
The best concentration of adrenaline is 1:200 000 (5 mcg/mL). This gives
maximum local effect with the least risk of toxicity from the adrenaline
itself (Table C-3, page C-40).
Note: It is critical to measure adrenaline carefully and accurately using a

syringe such as a BCG or insulin syringe. Mixtures must be prepared
observing strict infection prevention practices (page C-17).
TABLEC-3 Formulas for preparing 0.5% lignocaine solutions
containing 1:200 000 adrenaline
Desired Amount of Normal Saline/ Normal Saline/ Adrenaline

Local Anaesthetic Lignocaine 2% Lignocaine 1% 1:1000
Needed
20mL 15 mL/5 mL lOmL/lOmL 0.1 mL
40mL 30mL/10mL 20mL/20mL 0.2mL
lOOmL 75 mL/25 mL 50mL/50mL 0.5mL
200mL 150mL/50 mL 100 mL/100 mL l.OmL
COMPLICATIONS
PREVENTION OF COMPLICATIONS
All local anaesthetic drugs are potentially toxic. Major complications
from local anaesthesia are, however, extremely rare (Table C-5, page
C-41). The best way to avoid complications is to prevent them:
• Avoid using concentrations of lignocaine stronger than 0.5%.
• If more than 40 mL of the anaesthetic solution is to be used, add
adrenaline to delay dispersion. Procedures that may require more than
40 mL of 0.5% lignocaine are caesarean section or repair of extensive
perineal tears.
• Use the lowest effective dose.
• Observe the maximum safe dose. For an adult, this is 4 mg/kg body
weight of lignocaine without adrenaline and 7 mg/kg body weight of
lignocaine with adrenaline. The anaesthetic effect should last for at
least two hours. Doses can be repeated if needed after two hours (Table
C-4).
TABLEC-4 Maximum safe doses of local anaesthetic drugs
Drug Maximum Dose Maximum Dose for

(mglkg of body weight) 60 kg Adult (mg)
Lignocaine 4 240
Lignocaine + adrenaline 7 420

1:200 000 (5 mcg/mL)
• Inject slowly.
• A void accidental injection into a vessel. There are three ways of doing
this:
moving needle technique (preferred for tissue infiltration): the
needle is constantly in motion while injecting; this makes it
impossible for a substantial amount of solution to enter a vessel;
plunger withdrawal technique (preferred for nerve block when
considerable amounts are injected into one site): the syringe
plunger is withdrawn before injecting; if blood appears, the needle
is repositioned and attempted again;
syringe withdrawal technique: the needle is inserted and the
anaesthetic is injected as the syringe is being withdrawn.
To avoid lignocaine toxicity:

• use a dilute solution;
• add adrenaline when more than 40 mL will be used;
• use lowest effective dose;
• observe maximum dose;
• avoid IV injection.
DIAGNOSIS OF LIGNOCAINE ALLERGY AND TOXICITY

TABLE C-S Symptoms and signs of lignocaine allergy and
toxicity
Allergy Mild Toxicity Severe Toxicity Life-Threatening

Toxicity (very
rare)
• Shock • Numbness of • Sleepiness • Tonic-clonic

• Redness of lips and tongue • Disorientation convulsions
skin • Metallic taste • Muscle • Respiratory
• Skin rash/hives in mouth twitching and depression or
• Bronchospasm • Dizzinessnight shivering arrest
• Vomiting headedness • Slurred speech • Cardiac
• Serum sickness • Ringing in ears depression or
• Blurred vision arrest
MANAGEMENT OF LIGNOCAINE ALLERGY

Give adrenaline 1: 1000, 0.5 mL IM, repeated every 10 minutes if
necessary.
In acute situations, give hydrocortisone 100 mg IV every hour.
To prevent recurrence, give diphenhydramine 50 mg IM or IV
slowly, then 50 mg by mouth every six hours.
Treat bronchospasm with aminophylline 250 mg in normal saline
10 mL IV slowly.
Laryngeal oedema may require immediate tracheostomy.
For shock, begin standard shock management (page S-1).
Severe or recurrent signs may require corticosteroids (e.g.
hydrocortisone IV 2 mg/kg body weight every four hours until
condition improves). In chronic situations give prednisone 5 mg
or prednisolone 10 mg by mouth every six hours until condition
improves.
MANAGEMENT OF LIGNOCAINE TOXICITY

Symptoms and signs of toxicity (Table C-5, page C-41) should alert
tht; practitioner to immediately stop injecting and prepare to treat severe
and life-threatening side effects. If symptoms and signs of mild
toxicity are observed, wait a few minutes to see if the symptoms
subside, check vital signs, talk to the woman and then continue the
procedure, if possible.
CONVULSIONS
Turn the woman to her left side, insert an airway and aspirate
secretions.
Give oxygen at 6-8 L per minute by mask or nasal cannulae.
Give diazepam 1-5 mg IV in 1-mg increments. Repeat if
convulsions recur.
Note: The use of diazepam to treat convulsions may cause
respiratory depression.
RESPIRATORY ARREST
If the woman is not breathing, assist ventilation using an Ambu
bag and mask or via endotracheal tube; give oxygen at 4-6 L per
minute.
CARDIAC ARREST
• Hyperventilate with oxygen.
Perform cardiac massage.
If the woman has not yet delivered, immediately deliver the baby
by caesarean section (page P-43) using general anaesthesia.
Give adrenaline 1:10 000,0.5 mL IV.
ADRENALINE TOXICITY
-
Systemic adrenaline toxicity results from excessive amounts or
inadvertent IV administration and results in:
restlessness;
sweating;
hypertension;
cerebral haemorrhage;
rapid heart rate;
ventricular fibrillation.
Local adrenaline toxicity occurs when the concentration is
excessive, and results in ischaemia at the infiltration site with poor
healing.
GENERAL PRINCIPLES FOR ANAESTHESIA AND ANALGESIA

The keys to pain management and comfort of the woman are:
supportive attention from staff before, during and after a
procedure (helps reduce anxiety and lessen pain);
a provider who is comfortable working with women who are
awake and who is trained to use instruments gently;
the selection of an appropriate type and level of pain
medication.
Tips for performing procedures on women who are awake include:
Explain each step of the procedure before performing it;
Use adequate premedication in cases expected to last longer
than 30 minutes;
Give analgesics or sedatives at an appropriate time before the

procedure (30 minutes before for IM and 60 minutes before for
oral medication) so that maximum relief will be provided
during the procedure;
Use dilute solutions in adequate amounts;
Check the level of anaesthesia by pinching the area with
forceps. If the woman feels the pinch, wait two minutes and
then retest;
Wait a few seconds after performing eaG,b step or task for the
woman to prepare for the next one;
Move slowly, without jerky or quick motions;
Handle tissue gently and avoid undue retraction, pulling or
pressure;
Use instruments with confidence;
Avoid saying things like "this won't hurt" when, in fact, it will
hurt; or "I'm almost finished" when you are not;
Talk with the woman throughout the procedure.
The need for supplemental analgesic or sedative medications (by
mouth, IM or IV) will depend on:
the emotional state of the woman;
the procedure to be performed (Table C-6, page C-45);
the anticipated length of the procedure;
the skill of the provider and the assistance of the staff.
TABLEC-6 Analgesia and anaesthesia options

Procedure Analgesia/Anaesthesia Options•
Breech delivery • General methods of labour support (page C-57)
• Pudendal block (page P-3)
Caesarean section • Spinal anaesthesia (page P-11)
• Local anaesthesia (page P-7)
• Ketamine (page P-13)
• General anaesthesia
Cervical tears • Pethidine and diazepam (page C-38)
(extensive) • Ketamine (page P-13)
Colpotomy/ • Local anaesthesia (page C-38)
Culdocentesis
Craniotomy/ • Emotional support and encouragement (page C-7)
Craniocentesis • Diazepam (page C-38)
Dilatation and • Paracervical block (page P-1)
curettage • Pethidine (page C-38)
Episiotomy • Local anaesthesia (page C-38)
Forceps delivery • Emotional support and encouragement (page C-7)
Labour and childbirth • General methods of labour support (page C-57)
• Pethidine and promethazine (page C-38)
Laparotomy • General anaesthesia
• Spinal anaesthesia (page P-11)
11anualremovalof • Pethidine and diazepam (page C-38)
placenta • Ketamine (page P-13)
MVA • Paracervical block (page P-1)
• Pethidine (page C-38)
Perineal tears (first • Local anaesthesia (page C-38)
and second degree) • Pudendal block (page P-3)
Perineal tears (third • Pudendal block (page P-3)
and fourth degree) • Ketarnine (page P-13)
• Local anaesthesia, pethidine, and diazepam (page C-38)
• Spinal anaesthesia (page P-11)
Symphysiotomy • Local anaesthesia (page C-38)
Uterine inversion • Pethidine and diazepam (page C-38)
(correction of) • General anaesthesia
Vacuum extraction • Emotional support and encouragement (page C-7)
"The preferred analgesia/anaesthesia option is listed in bold.
POSTOPERATIVE ANALGESIA
Adequate postoperative pain control is important. A woman who is in
severe pain does not recover well. '
Note: Avoid over sedation as this will limit mobility, which is
important during the postoperative period.
Good postoperative pain control regimens include:
non-narcotic mild analgesics such as paracetamol 500 mg by
mouth as needed;
• narcotics such as pethidine 1 mglkg body weight (but not more
than 100 mg) IM or IV slowly or morphine 0.1 mg/k:g body weight
IM every four hours as needed;
• combinations of lower doses of narcotics with paracetamol.
Note: If the woman is vomiting, narcotics may be combined with anti-
emetics such as promethazine 25 mg IM or IV every four hours as
needed.
OPERATIVE CARE PRINCIPLES C-47
The woman is the primary focus of the physician/midwife and nurse

during any procedure. The surgical or scrub nurse has her attention
focused on the procedure and the needs of the physician/midwife
performing the procedure.
PRE-OPERATIVE CARE PRINCIPLES
PREPARING THE OPERATING THEATRE

Ensure that:
the operating theatre is clean (it should be cleaned after every
procedure);
necessary supplies and equipment are available, including drugs
and an oxygen cylinder;
emergency equipment is available and in working order;
there are adequate supply of theatre dress for the anticipated
members of the surgical team;
clean linens are available;
sterile supplies (gloves, gauze, instruments) are available and not
beyond expiry date.
PREPARING THE WOMAN FOR A SURGICAL PROCEDURE

Explain the procedure to be performed and its purpose to the
woman. If the woman is unconscious, explain the procedure to her
family.
Obtain informed consent for the procedure.
Assist the woman and her family to prepare emotionally and
psychologically for the procedure (page C-7).
Review the woman's medical history:
Check for any possible allergies;
Ensure that the woman has received the complete antitetanus
regimen and give one dose of tetanus vaccine, if necessary.
Send a blood sample for haemoglobin or haematocrit and type and
screen, and order blood for possible transfusion. Do not delay
transfusion if needed.
C-48 Operative care principles
Wash the area around the proposed incision site with soap and
water, if necessary.
Do not shave the woman's pubic hair as this increases the risk of
wound infection. The hair may be trimmed, if necessary.
Monitor and record vital signs (blood pressure, pulse, respiratory
rate and temperature).
Administer premedication appropriate for the anaesthesia used
(page C-38).
Give an antacid (sodium citrate 0.3% 30 mL or magnesium
trisilicate 300 mg) to reduce stomach acid in case there is
aspiration.
Catheterize the bladder if necessary and monitor urine output.
Ensure that all relevant information is passed on to other members
of the team (doctor/midwife, nurse, anaesthetist, assistant and
others).
INTRA-OPERATIVE CARE PRINCIPLES
POSITION
Place the woman in a position appropriate for the procedure to allow:
optimum exposure of the operative site;
• access for the anaesthetist;
• access for the nurse to take vital signs and monitor IV drugs and
infusions;
safety of the woman by preventing injuries and maintaining
circulation;
maintenance of the woman's dignity and modesty.
Note: If the woman has not delivered, have the operating table tilted
to the left or place a pillow or folded linen under her right lower back to
decrease supine hypotension syndrome.
SURGICAL HANDSCRUB
• Remove all jewelry.
• Hold hands above the level of the elbow, wet hands thoroughly and
apply soap (preferably an iodophore, e.g. betadine).
Begin at the fingertips and lather and wash, using a circular
motion:
Wash between all fingers;
Move from the fingertips to the elbows of one hand and then
repeat for the second hand;
Wash for three to five minutes.
Rinse each arm separately, fingertips first, holding hands above the
level of the elbows.
Dry hands with a clean or disposable towel, wiping from the
fingertips to the elbows, or allow hands to air dry.
• Ensure that scrubbed hands do not come into contact with objects
(e.g. equipment, protective gown) that are not high-level
disinfected or sterile. If the hands touch a contaminated surface,
repeat surgical handscrub.
PREPARING THE INCISION SITE

• Prepare the skin with an antiseptic (e.g. iodophors, chlorhexidine):
Apply antiseptic solution three times to the incision site using
a high-level disinfected or sterile ring forceps and cotton or
gauze swab. If the swab is held with a gloved hand, do not
contaminate the glove by touching unprepared skin;
Begin at the proposed incision site and work outward in a
circular motion away from the incision site;
At the edge of the sterile field discard the swab.
• Never go back to the middle of the prepared area with the same
swab. Keep your arms and elbows high and surgical dress away
from the surgical field.
Drape the woman immediately after the area is prepared to avoid
contamination:
If the drape has a window, place the window directly over the
incision site first.
Unfold the drape away from the incision site to avoid

contamination.
MONITORING
Monitor the woman's condition regularly throughout the procedure.
Monitor vital signs (blood pressure, pulse, respiratory rate), level
of consciousness and blood loss.
Record the findings on a monitoring sheet to allow quick
recognition if the woman's condition deteriorates.
Maintain adequate hydration throughout surgery.
MANAGING PAIN
Maintain adequate pain management throughout the procedure (page
C-37). Women who are comfortable during a procedure are less likely
to move and cause injury to themselves. Pain management can include:
emotional support and encouragement;
local anaesthesia;
regional anaesthesia (e.g. spinal);
general anaesthesia.
ANTIBIOTICS
Give prophylactic antibiotics before starting the procedure. If the
woman is going to have a caesarean section, give prophylactic
antibiotics after the baby is delivered (page C-35).
MAKING THE INCISION

Make the incision only as large as necessary for the procedure.
Make the incision with great care and proceed one layer at a time.
HANDLING TISSUE
Handle tissue gently.
When using clamps, close the clamp only one ratchet (click), when
possible. This will minimize discomfort and reduce the amount of
Operative care principles C·51
dead tissue that remains behind at the end of the procedure, thus
decreasing the risk of infection.
HAEMOSTASIS
Ensure haemostasis throughout the procedure.
Women with obstetrical complications often have anaemia.
Therefore, keep blood loss to a minimum.
INSTRUMENTS AND SHARPS

Start and finish the procedure with a count of instruments, sharps
and sponges:
Perform the count every time a body cavity (e.g. uterus) is
closed;
Document in the woman's record that the surgical counts were
correct.
• Use instruments, especially sharps, carefully to reduce the risk of
injury (page C-20). Use "safe zones" when handling and passing
instruments and sharps:
Use a pan such as a kidney basin to carry and pass sharp items,
and pass suture needles on a needle holder;
Alternatively, pass the instrument with the handle, rather than
the sharp end, pointing toward the receiver.
DRAINAGE
• Always leave an abdominal drain in place if:
bleeding persists after hysterectomy;
a clotting disorder is suspected;
infection is present or suspected.
A closed drainage system can be used or a corrugated rubber drain
can be placed through the abdominal wall or pouch of Douglas.
Remove the drain once the infection has cleared or when no pus or
blood-stained fluid has drained for 48 hours.
SUTURE
Select the appropriate type and size of suture for the tissue (Table
C-7). Sizes are reported by a number of "O"s:
Smaller suture has a greater number of "O"s [e.g. 000 (3-0)
suture is smaller than 00 (2-0) suture]; suture labeled as "1" is
larger in diameter than "0" suture;
A suture that is too small will be weak and may break easily; a
suture that is too large in diameter will tear through tissue.
Refer to the appropriate section for the recommended size and type
of suture for a procedure.
TABLEC-7 Recommended suture types
Suture Type Tissue Recommended Number of
Knots
Plain catgut Fallopian tube 3"
Chromic catgut Muscle, fascia 3"
Poly glycolic Muscle, fascia, skin 4
Nylon Skin 6
Silk Skin, bowel 3"
• These are natural sutures. Do not use more than three knots because this will
abrade the suture and weaken the knot.
DRESSING
At the conclusion of surgery, cover the surgical wound with a sterile
dressing (page C-54).
POSTOPERATIVE CARE PRINCIPLES
INITIAL CARE
Place the woman in the recovery position:
Position the woman on her side with her head slightly
extended to ensure a clear airway;
Place the upper arm in front of the body for easy access to
check blood pressure;
Place legs so that they are flexed, with the upper leg slightly
more flexed than the lower to maintain balance.
Assess the woman's condition immediately after the procedure:
Check vital signs (blood pressure, pulse, respiratory rate) and
temperature every 15 minutes during the first hour, then every
30 minutes for the next hour;
Assess the level of consciousness every 15 minutes until the
woman is alert.
Note: Ensure the woman has constant supervision until
conscious.
Ensure a clear airway and adequate ventilation.
• Transfuse if necessary (page C-23).
• If vital signs become unstable or if the haematocrit continues to
fall despite transfusion, quickly return to the operating theatre
because bleeding may be the cause.
GASTROINTESTINAL FUNCTION
Gastrointestinal function typically returns rapidly for obstetrical
patients. For most uncomplicated procedures, bowel function should be
normal within 12 hours of surgery.
If the surgical procedure was uncomplicated, give a liquid diet.
If there were signs of infection, or if the caesarean was for
obstructed labour or uterine rupture, wait until bowel sounds
are heard before giving liquids.
When the woman is passing gas, begin giving solid food.
If the woman is receiving IV fluids, continue the fluids until she
is taking liquids well.
If you anticipate that the woman will receive IV fluids for 48
hours or more, infuse a balanced electrolyte solution (e.g.
potassium chloride 1.5 gin 1 L IV fluids).
If the woman receives IV fluids for more than 48 hours, monitor
electrolytes every 48 hours. Prolonged infusion of IV fluids can
alter electrolyte balance.
Ensure the woman is eating a regular diet prior to discharge from
hospital.
DRESSING AND WOUND CARE

The dressing is a protective barrier against infection while a healing
process known as "re-epithelialization" occurs. Keep the dressing on
the wound for the first day after surgery to protect against infection
while re-epithelialization occurs. Thereafter, a dressing is not
necessary.
• If blood or fluid is leaking through the initial dressing, do not
change the dressing:
Reinforce the dressing;
Monitor the amount of blood/fluid lost by outlining the blood
stain on the dressing with a pen;
If bleeding increases or the blood stain covers half the
dressing or more, remove the dressing and inspect the wound.
Replace with another sterile dressing.
If the dressing comes loose, reinforce with more tape rather than
removing the dressing. This will help maintain the sterility of the
dressing and reduce the risk of wound infection.
Change the dressing using sterile technique.
The wound should be clean and dry, without evidence of infection
or seroma prior to the woman's discharge from the hospital.
ANALGESIA
Adequate postoperative pain control is important (page C-37). A
woman who is in severe pain does not recover well.
Note: Avoid over-sedation as this will limit mobility, which is
important during the postoperative period.
BLADDER CARE
A urinary catheter may be required for some procedures. Early catheter
removal reduces the risk of infection and encourages the woman to walk.
If the urine is clear, remove the catheter eight hours after surgery
or after the first postoperative night.
If the urine is not clear, leave the catheter in place until the urine
is clear.
Wait 48 hours after surgery before removing the catheter if there
was:
uterine rupture;
prolonged or obstructed labour;
massive perineal oedema;
puerperal sepsis with pelvic peritonitis.
Note: Ensure that the urine is clear before removing the catheter.
• If the bladder was injured (either from uterine rupture or during
caesarean section or laparotomy):
Leave the catheter in place for a minimum of seven days and
until the urine is clear;
If the woman is not currently receiving antibiotics, give
nitrofurantoin 100 mg by mouth once daily until the catheter is
removed, for prophylaxis against cystitis.
ANTIBIOTICS
If there were signs of infection or the woman currently has
fever, continue antibiotics until the woman is fever-free for 48
hours (page C-35).
SUTURE REMOVAL
Major support for abdominal incisions comes from the closure of the
fasciallayer. Remove skin sutures five days after surgery.
FEVER
• Fever (temperature 38°C or more) that occurs postoperatively
should be evaluated (page S-107).
Ensure the woman is fever-free for a minimum of 24 hours prior to
discharge from hospital.
AMBULATION
Ambulation enhances circulation, encourages deep breathing and
stimulates return of normal gastrointestinal function. Encourage foot
and leg exercises and mobilize as soon as possible, usually within 24
hours.
NORMAL LABOUR AND CHILDBIRTH C-57
NORMAL LABOUR
Perform a rapid evaluation of the general condition of the woman
including vital signs (pulse, blood pressure, respiration,
temperature).
Assess fetal condition:
Listen to the fetal heart rate immediately after a contraction:
Count the fetal heart rate for a full minute at least once
every 30 minutes during the active phase and every five
minutes during the second stage;
If there are fetal heart rate abnormalities (less than 100
or more than 180 beats per minute), suspect fetal distress
(page S-95).
If the membranes have ruptured, note the colour of the
draining amniotic fluid:
Presence of thick meconium indicates the need for close
monitoring and possible intervention for management of
fetal distress (page S-95);
Absence of fluid draining after rupture of the membranes
is an indication of reduced volume of amniotic fluid,
which may be associated with fetal distress.
SUPPORTIVE CARE DURING LABOUR AND CHILDBIRTH

Encourage the woman to have personal support from a person of
her choice throughout labour and birth:
Encourage support from the chosen birth companion;
Arrange seating for the companion next to the woman;
Encourage the companion to give adequate support to the
woman during labour and childbirth (rub her back, wipe her
brow with a wet cloth, assist her to move about).
Ensure good communication and support by staff:
Explain all procedures, seek permission and discuss findings
with the woman;
C-58 Normal labour and childbirth
Provide a supportive, encouraging atmosphere for birth that is

respectful ofthe woman's wishes;
Ensure privacy and confidentiality.
Maintain cleanliness of the woman and her environment:
Encourage the woman to wash herself or bathe or shower at
the onset of labour;
Wash the vulval and perineal areas before each examination;
Wash your hands with soap before and after each examination;
Ensure cleanliness of labouring and birthing area(s);
Clean up all spills immediately.
• Ensure mobility:
Encourage the woman to move about freely;
Support the woman's choice of position during labour and
birth (Fig C-2, page C-59).
Encourage the woman to empty her bladder regularly.
Note: Do not routinely give an enema to women in labour.
Encourage the woman to eat and drink as she wishes. If the
woman has visible severe wasting or tires during labour, make
sure she is fed. Nutritious liquid drinks are important, even in late
labour.
Teach breathing techniques for labour and delivery. Encourage the
woman to breathe out more slowly than usual and relax with each
expiration.
Help the woman in labour who is anxious, fearful or in pain:
Give her praise, encouragement and reassurance;
Give her information on the process and progress of her
labour;
Listen to the woman and be sensitive to her feelings.
If the woman is distressed by pain:
Suggest changes of position (Fig C-2, page C-59);
Encourage mobility;
Encourage her companion to massage her back or hold her
hand and sponge her face between contractions;
Normal labour and childbirth C-59
Encourage breathing techniques;

Encourage warm bath or shower;
If necessary, give pethidine 1 mg/kg body weight (but not
more than 100 mg) IM or IV slowly or give morphine 0.1
mg/kg body weight IM.
FIGURE C-2 Some positions that a woman may adopt during
labour and birth
DIAGNOSIS
Diagnosis of labour includes:
• diagnosis and confirmation of labour;
diagnosis of stage and phase of labour;
assessment of engagement and descent of the fetus;
identification of presentation and position of the fetus.
An incorrect diagnosis of labour can lead to unnecessary

anxiety and interventions.
DIAGNOSIS AND CONFIRMATION OF LABOUR

• Suspect or anticipate labour if the woman has:
intermittent abdominal pain after 22 weeks gestation;
pain often associated with blood-stained mucus discharge (show);
watery vaginal discharge or a sudden gush of water.
Confirm the onset of labour if there is:
cervical effacement-the progressive shortening and thinning

of the cervix during labour; and
cervical dilatation-the increase in diameter of the cervical
opening measured in centimetres (Fig C-3 A-E).
FIGUREC-3 Effacement and dilatation of the cervix
A 8 c 0 E
Cervix not Cervix partly Cervix Cervix Cervix
effaced. effaced. fully dilated dilated
Length of Length of effaced 3cm Bern
cervical cervical
canal =4cm canal =2 cm
DIAGNOSIS OF STAGE AND PHASE OF LABOUR

TABLEC-8 Diagnosis of stage and phase of labour•
Symptoms and Signs Stage Phase
• Cervix not dilated False labour/

Not in labour
• Cervix dilated less than 4 cm First Latent
• Cervix dilated 4-9 cm First Active

• Rate of dilatation typically 1 cm per
hour or more
• Fetal descent begins
• Cervix fully dilated (10 cm) Second Early (non-

• Fetal descent continues expulsive)
• No urge to push
• Cervix fully dilated (10 cm) Second Late (expulsive)

• Presenting part of fetus reaches pelvic
floor
• Woman has the urge to push
a The third stage of labour begins with delivery of the baby and ends with the
expulsion of the placenta.
DESCENT
ABDOMINAL PALPATION
By abdominal palpation, assess descent in terms of fifths of fetal
head palpable above the symphysis pubis (Fig C-4 A-D):
A head that is entirely above the symphysis pubis is five-fifths
(5/5) palpable (Fig C-4 A-B);
A head that is entirely below the symphysis pubis is zero-fifths
(0/5) palpable.
FIGURE C-4 Abdominal palpation for descent of tbe fetal bead
A. Head is mobile B. Head accommodates

above the full width of five
symphysis fingers above the
pubis= 5/5 symphysis pubis
C. Head is 215 D. Head accommodates

above symphysis two fingers above
pubis the symphysis pubis
VAGINAL EXAMINATION
• If necessary, a vaginal examination may be used to assess descent
by relating the level of the fetal presenting part to the ischial spines
of the maternal pelvis (Fig C-5, page C-62).
Note: When there is a significant degree of caput or moulding,

assessment by abdominal palpation using fifths of head palpable is
more useful than assessment by vaginal exam.
FIGUREC-5 Assessing descent of the fetal head by vaginal
examination; 0 station is at the level of the ischial
spine (Sp)
PRESENTATION AND POSITION
DETERMINE THE PRESENTING PART

• The most common presenting part is the vertex of the fetal head. If
the vertex is not the presenting part, manage as a
malpresentation (Table S-12, page S-73).
If the vertex is the presenting part, use landmarks on the fetal
skull to determine the position of the fetal head in relation to the
maternal pelvis (Fig C-6).
FIGURE C-6 Landmarks of the fetal skull
Posterior fontanelle
DETERMINE THE POSITION OF THE FETAL HEAD

The fetal head normally engages in the maternal pelvis in an
occiput transverse position, with the fetal occiput transverse in
the maternal pelvis (Fig C-7).
FIGURE C-7 Occiput transverse positions
Left occiput transverse Right occiput transverse
With descent, the fetal head rotates so that the fetal occiput is
anterior in the maternal pelvis (occiput anterior positions, Fig
C-8). Failure of an occiput transverse position to rotate to an
occiput anterior position should be managed as an occiput posterior
position (page S-75).
FIGURE C-8 Occiput anterior positions
Left occiput anterior Right occiput anterior
Occiput anterior
An additional feature of a normal presentation is a well-flexed

vertex (Fig C-9), with the occiput lower in the vagina than the
sinciput.
FIGUREC-9 Well-flexed vertex
Sinciput
Occiput
ASSESSMENT OF PROGRESS OF LABOUR

Once diagnosed, progress of labour is assessed by:
• measuring changes in cervical effacement and dilatation (Fig C-3
A-E, page C-60) during the latent phase;
• measuring the rate of cervical dilatation and fetal descent (Fig C-4,
page C-61 and Fig C-5, page C-62) during the active phase;
assessing further fetal descent during the second stage.
Progress of the first stage of labour should be plotted on a partograph
once the woman enters the active phase of labour. A sample partograph
is shown in Fig C-10, page C-67. Alternatively, plot a simple graph of
cervical dilatation (centimetres) on the vertical axis against time (hours)
on the horizontal axis.
VAGINAL EXAMINATIONS
Vaginal examinations should be carried out at least once every four
hours during the first stage of labour and after rupture of the
membranes. Plot the findings on a partograph.
At each vaginal examination, record the following:
colour of amniotic fluid;
cervical dilatation;
descent (can also be assessed abdominally).
• If the cervix is not dilated on first examination it may not be

possible to diagnose labour.
If contractions persist, re-examine the woman after four
hours for cervical changes. At this stage, if there is effacement
and dilatation, the woman is in labour; if there is no change,
the diagnosis is false labour.
In the second stage of labour, perform vaginal examinations once
every hour.
USING THE PARTOGRAPH

The WHO partograph has been modified to make it simpler and easier
to use. The latent phase has been removed and plotting on the
partograph begins in the active phase when the cervix is 4 cm dilated. A
sample partograph is included (Fig C-10, page C-67). Note that the
partograph should be enlarged to full size before use. Record the
following on the partograph:
Patient information: Fill out name, gravida, para, hospital number,
date and time of admission, and time of ruptured membranes or time
elapsed since rupture of membranes (if rupture occurred before charting
on the partograph began).
Fetal heart rate: Record every half hour.
Amniotic fluid: Record the colour of amniotic fluid at every vaginal
examination:
1: membranes intact;
R: membranes ruptured;
C: membranes ruptured, clear fluid;
M: meconium-stained fluid;
B: blood-stained fluid.
Moulding:
1: sutures apposed;
2: sutures overlapped but reducible;
3: sutures overlapped and not reducible.
Cervical dilatation: Assessed at every vaginal examination and
marked with a cross (X). Begin plotting on the partograph at 4 cm.
Alert line: A line starts at 4 cm of cervical dilatation to the point of

expected full dilatation at the rate of 1 cm per hour.
,Action line: Parallel and four hours to the right of the alert line.
Descent assessed by abdominal palpation: Refers to the part of the
head (divided into five parts) palpable above the symphysis pubis;
recorded as a circle (0) at every abdominal examination. At 0/5, the
sinciput (S) is at the level of the symphysis pubis.
5/5 4/5 3/5 2/5 1/5 0/5
Completely Sinciput Sinciput Sinciput Sinciput None

above high, easily felt, felt, felt, of head
Occiput Occiput Occiput Occiput palpable
easily felt felt just felt not felt
Hours: Refers to the time elapsed since onset of active phase of labour
(observed or extrapolated).
Time: Record actual time.
Contractions: Chart every half hour; count the number of contractions
in a 10-minute time period, and their duration in seconds.
• Less than 20 seconds: 0

Between 20 and 40 seconds: ~
More than 40 seconds: •
Oxytocin: Record the amount of oxytocin per volume IV fluids in
drops per minute every 30 minutes when used.
Drugs given: Record any additional drugs given.
Pulse: Record every 30 minutes and mark with a dot ( • ).
Blood pressure: Record every four hours and mark with arrows.
Temperature: Record every two hours.
Protein, acetone and volume: Record when urine is passed.
FIGURE C-10 The modified WHO Partograph

Name Gravida Para Hospital number
Date of admission Time of admission Ruptured membranes hours
200
190
180
170
180
Fetal 150
heart 140
rate 130
120
110
100
90
80
Amniotic fluid
Moulding IIIIIIIIIIIIIIIIIIIIIIIII
V" V
I ,: I V I I /,
~0~ I ~0~
Cervix(an)
J>' ~c;,
'/
[Pli~XT : V
V
V"
Descent
"
ofhead 3
[PlO):
Hours 1 2 3
• 5 6 7 8 9 10 11 12
Time
~:~1111111111 i Ill 1111111111 I
Drugs given
and IV fluids
Figure C-11, page C-69 is a sample partograph for normal labour:

A primigravida was admitted in the latent phase of labour at 5 AM:
fetal head was 4/5 palpable;
cervix dilated 2 cm;
three contractions in lO minutes, each lasting 20 seconds;
normal maternal and fetal condition.
Note: Because the woman was in the latent phase of labour, this
information is not plotted on the partograph.
At9AM:
fetal head 3/5 palpable;
four contractions in 10 minutes, each lasting 35 seconds.
Note: The woman was in the active phase of labour and this
information is plotted on the partograph. Cervical dilatation is
plotted on the alert line.
At 11 AM:
four contractions in 10 minutes, each lasting 45 seconds.
At 1 PM:
cervical dilatation progressed at rate of more than 1 cm per
hour and cervix fully dilated;
five contractions in 10 minutes each lasting 45 seconds;
spontaneous vaginal delivery at 1:20PM.
FIGURE C-11 Sample partograph for normal labour

Name Mrs. S Gravida 3 Para 2+0 Hospital number 7886
Date of admission 12.!1.2000 Time of admission 5:00A.M. Ruptured membranes 1 hours

200
190
160
170
160
Fetal 150
heart 140
rate 130 V
120
110
100
90
60
Amniotic fluid
Moulding I I IEI'I'I'I'I'I'I'I I I I I I I I I I I I I I I
r
10
~ v V
I v V I I
&oS" ""'
p ~""'
...\i
Cervix(an)
[Plot X[
1
v:;,...
.i~ V 'S1'1l 3: l!a
"' 1
:.,;~"' v Ll e felncle
lirr art
~-- w. 2,"!50
r-,
r-1'-..
Hours 1 2 3 4 5 6 7 B 9 10 11 12
Time 9 10 11 12 13
Oxytocin UIL
drops/m in
I '/r•
~~~~~
IIIIIIIIIIIIIIIIIIIIIIIII
11 I I I Ill
Drugs given
and IV fluids
160
170
160
Pulse • 150
a~:r l~ 100 ... lA

90
60
70
60
Temp"CI 136.81 I 371 I

~~~~~~~~~~~~~
-E:I 1;1 I 1~1 I I I I I I '

PROGRESS OF FIRST STAGE OF LABOUR

• Findings suggestive of satisfactory progress in the first stage of
labour are:
regular contractions of progressively increasing frequency and
duration;
rate of cervical dilatation at least 1 cm per hour during the
active phase of labour (cervical dilatation on or to the left of
alert line);
cervix well applied to the presenting part.
Findings suggestive of unsatisfactory progress in the first stage of
labour are:
irregular and infrequent contractions after the latent phase;
OR rate of cervical dilatation slower than 1 cm per hour during
the active phase oflabour (cervical dilatation to the right of
alert line);
OR cervix poorly applied to the presenting part.
Unsatisfactory progress in labour can lead to prolonged labour (Table
S-10, pageS-57).
PROGRESS OF SECOND STAGE OF LABOUR

Findings suggestive of satisfactory progress in the second stage
of labour are:
steady descent of fetus through birth canal;
onset of expulsive (pushing) phase.
• Findings suggestive of unsatisfactory progress in second stage of
labour are:
lack of descent of fetus through birth canal;
failure of expulsion during the late (expulsive) phase.
PROGRESS OF FETAL CONDITION

If there are. fetal heart rate abnormalities (less than 100 or more
than 180 beats per minute), suspect fetal distress (page S-95).
Positions or presentations in labour other than occiput anterior with

a well-flexed vertex are considered malpositions or
malpresentations (page S-69).
If unsatisfactory progress of labour or prolonged labour is
suspected, manage the cause of slow progress (pageS-57).
PROGRESS OF MATERNAL CONDITION

Evaluate the woman for signs of distress:
If the woman's pulse is increasing, she may be dehydrated or in
pain. Ensure adequate hydration via oral or IV routes and provide
adequate analgesia (page C-37).
• If the woman's blood pressure decreases, suspect haemorrhage
(page S-17).
If acetone is present in the woman's urine, suspect poor nutrition
and give dextrose IV.
NORMAL CHILDBIRTH
General methods of supportive care during labour are most

useful in helping the woman tolerate labour pains.
Once the cervix is fully dilated and the woman is in the expulsive
phase of the second stage, encourage the woman to assume the
position she prefers (Fig C-12) and encourage her to push.
FIGURE C-12 Some positions that a woman may adopt during
childbirth
C·72 Normal labour and childbirth
Note: Episiotomy is no longer recommended as a routine procedure.

There is no evidence that routine episiotomy decreases perineal
damage, future vaginal prolapse or urinary incontinence. In fact, routine
episiotomy is associated with an increase of third and fourth degree
tears and subsequent anal sphincter muscle dysfunction.
Episiotomy (page P-71) should be considered only in the case

of:
• complicated vaginal delivery (breech, shoulder dystocia,
forceps, vacuum extraction);
• scarring from female genital cutting or poorly healed third or
fourth degree tears;
• fetal distress.
DELIVERY OF THE HEAD

Ask the woman to pant or give only small pushes with contractions
as the baby's head delivers.
• To control birth of the head, place the fingers of one hand against
the baby's head to keep it flexed (bent).
• Continue to gently support the perineum as the baby's head
delivers.
Once the baby's head delivers, ask the woman not to push.
Suction the baby's mouth and nose.
• Feel around the baby's neck for the umbilical cord:
If the cord is around the neck but is loose, slip it over the
baby's head;
If the cord is tight around the neck, doubly clamp and cut it
before unwinding it from around the neck.
COMPLETION OF DELIVERY
Allow the baby's head to turn spontaneously.
• After the head turns, place a hand on each side of the baby's head.
Tell the woman to push gently with the next contraction.
• Reduce tears by delivering one shoulder at a time. Move the baby's
head posteriorly to deliver the shoulder that is anterior.
Note: If there is difficulty delivering the shoulders, suspect

shoulder dystocia (page S-83).
• Lift the baby's head anteriorly to deliver the shoulder that is
posterior.
Support the rest of the baby's body with one hand as it slides out.
Place the baby on the mother's abdomen. Thoroughly dry the baby,
wipe the eyes and assess the baby's breathing:
Note: Most babies begin crying or breathing spontaneously within
30 seconds of birth:
If the baby is crying or breathing (chest rising at least 30
times per minute) leave the baby with the mother;
If baby does not start breathing within 30 seconds, SHOUT
FOR HELP and take steps to resuscitate the baby (pageS-
142).
Anticipate the need for resuscitation and have a plan to get

assistance for every baby but especially if the mother has a
history of eclampsia, bleeding, prolonged or obstructed
labour, preterm birth or infection.
• Clamp and cut the umbilical cord within one minute of delivery of
the baby.
Ensure that the baby is kept warm and in skin-to-skin contact on
the mother's chest. Wrap the baby in a soft, dry cloth, cover with a
blanket and ensure the head is covered to prevent heat loss.
• If the mother is not well, ask an assistant to care for the baby.
• Palpate the abdomen to rule out the presence of an additional
baby(s) and proceed with active management of the third stage.
ACTIVE MANAGEMENT OF THE THIRD STAGE

Active management of the third stage (active delivery of the placenta)
helps prevent postpartum haemorrhage. Active management of the third
stage of labour includes:
• immediate oxytocin;
controlled cord traction; and
uterine massage.
OXYTOCIN
Within one minute of delivery of the baby, palpate the abdomen to
rule out the presence of an additional baby(s) and give oxytocin 10
units IM.
Oxytocin is preferred because it is effective two to three minutes
after injection, has minimal side effects and can be used in all
women. If oxytocin is not available, give ergometrine 0.2 mg IM
or prostaglandins. Make sure there is no additional baby(s) before
giving these medications.
Do not give ergometrine to women with pre-eclampsia,

eclampsia or high blood pressure because it increases the risk
of convulsions and cerebrovascular accidents.
CONTROLLED CORD TRACTION

Clamp the cord close to the perineum using sponge forceps within
one minute of delivery. Hold the clamped cord and the end of
forceps with one hand.
Place the other hand just above the woman's pubic bone and
stabilize the uterus by applying counter traction during controlled
cord traction. This helps prevent inversion of the uterus.
Keep slight tension on the cord and await a strong uterine
contraction (two to three minutes).
When the uterus becomes rounded or the cord lengthens, very
gently pull downward on the cord to deliver the placenta. Do not
wait for a gush of blood before applying traction on the cord.
Continue to apply counter traction to the uterus with the other
hand.
If the placenta does not descend during 30 to 40 seconds of
controlled cord traction (i.e. there are no signs of placental
separation), do not continue to pull on the cord:
Gently hold the cord and wait until the uterus is well
contracted again. If necessary, use a sponge forceps to clamp
the cord closer to the perineum as it lengthens;
With the next contraction, repeat controlled cord traction with
counter traction.
Never apply cord traction (pull) without applying counter

traction (push) above the pubic bone with the other hand.
As the placenta delivers, the thin membranes can tear off. Hold the
placenta in two hands and gently turn it until the membranes are
twisted.
• Slowly pull to complete the delivery.
If the membranes tear, gently examine the upper vagina and
cervix wearing high-level disinfected or sterile gloves and use a
sponge forceps to remove any pieces of membrane that are present.
Look carefully at the placenta to be sure none of it is missing. If a
portion of the maternal surface is missing or there are torn
membranes with vessels, suspect retained placental fragments
(page S-32).
If uterine inversion occurs, reposition the uterus (page P-91).
If the cord is pulled off, manual removal of the placenta may be
necessary (page P-77).
UTERINE MASSAGE
Immediately massage the fundus of the uterus through the
woman's abdomen until the uterus is contracted.
Repeat uterine massage every 15 minutes for the first two hours.
Ensure that the uterus does not become relaxed (soft) after you stop
uterine massage.
EXAMINATION FOR TEARS

Examine the woman carefully and repair any tears to the cervix
(page P-81) or vagina (page P-83) or repair episiotomy (page
P-73).
INITIAL CARE OF THE NEWBORN

Check the baby's breathing and colour every five minutes.
If the baby becomes cyanotic (bluish) or is having difficulty

breathing (less than 30 or more than 60 breaths per minute), give
oxygen by nasal catheter or prongs (page S-146).
• Check warmth by feeling the baby's feet every 15 minutes:
If the baby's feet feel cold, check axillary temperature;
If the baby's temperature is less than 36.5°C, rewarm the
baby (page S-148).
• Check the cord for bleeding every 15 minutes. If the cord is
bleeding, retie the cord more tightly.
Apply antimicrobial drops (1% silver nitrate solution or 2.5%
povidone-iodine solution) or ointment (1% tetracycline ointment)
to the baby's eyes.
Note: Povidone-iodine should not be confused with tincture of
iodine, which could cause blindness if used.
Wipe off any meconium or blood from skin.
Encourage breastfeeding when the baby appears ready (begins
"rooting"). Do not force the baby to the breast.
A void separating mother from baby whenever possible. Do

not leave mother and baby unattended at any time.
NEWBORN CARE PRINCIPLES C-77
When a baby is born to a mother being treated for complications, the
management of the newborn will depend on:
• whether the baby has a condition or problem requiring rapid
treatment;
whether the mother's condition permits her to care for her newborn
completely, partially or not at all.
NEWBORN BABIES WITH PROBLEMS

• If the newborn has an acute problem that requires treatment
within one hour of delivery, health care providers in the labour
ward will be required to give the care (page S-141). Problems or
conditions of the newborn requiring urgent interventions include:
gasping or not breathing;
breathing with difficulty (less than 30 or more than 60 breaths
per minute, indrawing of the chest or grunting);
central cyanosis (blueness);
preterm or very low birth weight (less than 1500 g);
lethargy;
hypothermia (axillary temperature less than 36.5°C);
convulsions.
• The following conditions require early treatment:
low birth weight (1500-2500 g);
possible bacterial infection in an apparently normal newborn
whose mother had prelabour or prolonged rupture of
membranes or amnionitis;
possible congenital syphilis (mother has positive serologic test
or is symptomatic).
If the newborn has a malformation or other problem that does
not require urgent (labour ward) care:
Provide routine initial newborn care (page C-75);
Transfer the baby to the appropriate service to care for sick
newborns as quickly as possible (page C-78).
C-78 Newbom care principles
NEWBORN BABIES WITHOUT PROBLEMS

• If the newborn has no apparent problems, provide routine initial
newborn care, including skin-to-skin contact with the mother and
early breastfeeding (page C-75).
• If the mother's condition permits, keep the baby in skin-to-skin
contact with the mother at all times.
If the mother's condition does not permit her to maintain skin-
to-skin contact with the baby after the delivery (e.g. caesarean
section):
Wrap the baby in a soft, dry cloth, cover with a blanket and
ensure the head is covered to prevent heat loss;
Observe frequently.
If the mother's condition requires prolonged separation from
the baby, transfer the baby to the appropriate service to care for
newborns (see below).
TRANSFERRING NEWBORN BABIES

Explain to the mother why the baby is being transferred (page
C-5).
• Keep the baby warm. Wrap the baby in a soft, dry cloth, cover with
a blanket and ensure the head is covered to prevent heat loss.
• Transfer the baby in the arms of a health care provider if possible.
If the baby requires special treatment such as oxygen, transfer
in an incubator or bassinet.
Initiate breastfeeding as soon as the baby is ready to suckle or as
soon as the mother's condition permits.
If breastfeeding has to be delayed due to maternal or newborn
problems, teach the mother to express breastmilk as soon as
possible and ensure that this milk is given to the newborn.
Ensure that the service caring for the newborn receives the record
of the labour and delivery and of any treatments given to the
newborn.
PROVIDER AND COMMUNITY LINKAGES C-79
CREATING AN IMPROVED HEALTH CARE ENVIRONMENT

The district hospital should strive to create a welcoming environment
for women, communities and providers from peripheral health units. It
should support the worthy efforts of other providers and work with
them to correct deficiencies.
When dealing with other providers, doctors and midwives at the district
hospital should:
encourage and thank providers who refer patients, especially in the
presence of the woman and her family;
offer clinical guidance and corrective suggestions in private, so as
to maintain the provider's credibility in the community;
• involve the provider (to an appropriate extent) in the continued
care of the woman.
When dealing with the community, doctors and midwives at the district
hospital should:
invite members of the community to be part of the district hospital
or health development committee;
• identify key persons in the community and invite them to the facility
to learn about its function, as well as its constraints and limitations;
create opportunities for the community to view the district hospital
as a wellness facility (e.g. through vaccination campaigns and
screening programs).
MEETING THE NEEDS OF WOMEN

To enhance its appeal to women and the community, the district
hospital should examine its own service delivery practices. The facility
should create a culturally sensitive and comfortable environment
which:
respects the woman's modesty and privacy;
• welcomes family members;
• provides a comfortable place for the woman and/or her newborn
(e.g. lower delivery bed, warm and clean room).
With careful planning, the facility can create this environment without
interfering with its ability to respond to complications or emergencies.
C-80 Provider and community linkages
IMPROVING REFERRAL PATTERNS

Each woman who is referred to the district hospital should be given a
standard referral slip containing the following information:
• general patient information (name, age, address);
obstetrical history (parity, gestational age, complications in the
antenatal period);
• relevant past obstetrical complications (previous caesarean section,
postpartum haemorrhage);
• the specific problem for which she was referred;
• treatments applied thus far and the results of those treatments.
Include the outcome of the referral on the referral slip. Send the
referral slip back to the referring facility with the woman or the
person who brought her. Both the district hospital and the referring
facility should keep a record of all referrals as a quality assurance
mechanism:
Referring facilities can assess the success and appropriateness of
their referrals;
The district hospital can review the records for patterns indicating
that a provider or facility needs additional technical support or
training.
PROVIDING TRAINING AND SUPPORTIVE SUPERVISION

District hospitals should offer clinical training for peripheral providers
that is high-quality and participatory. Participatory training is skill-
focused and is more effective than classroom-based training because it:
improves the relationship between providers at the district hospital
and the auxiliary and multipurpose workers from peripheral units;
• increases the familiarity of the peripheral providers with the
clinical care provided at the district hospital;
promotes team building and facilitates supervision of health
workers once they return to their community to implement the
skills they have learned.
SECTION 2
SYMPTOMS
SHOCK s-1
Shock is characterized by failure of the circulatory system to maintain
adequate perfusion of the vital organs. Shock is a life-threatening
condition that requires immediate and intensive treatment.
Suspect or anticipate shock if at least one of the following is present:
• bleeding in early pregnancy (e.g. abortion, ectopic or molar
pregnancy);
bleeding in late pregnancy or labour (e.g. placenta praevia,
abruptio placentae, ruptured uterus);
bleeding after childbirth (e.g. ruptured uterus, uterine atony, tears
of genital tract, retained placenta or placental fragments);
infection (e.g. unsafe or septic abortion, amnionitis, metritis, acute
pyelonephritis);
trauma {e.g. injury to uterus or bowel during abortion, ruptured
uterus, tears of genital tract).
SYMPTOMS AND SIGNS

Diagnose shock if the following symptoms and signs are present:
fast, weak pulse (110 per minute or more);
low blood pressure (systolic less than 90 mm Hg).
Other symptoms and signs of shock include:
• pallor (especially of inner eyelid, palms or around mouth);
• sweatiness or cold clammy skin;
rapid breathing (rate of 30 breaths per minute or more);
anxiousness, confusion or unconsciousness;
scanty urine output (less than 30 mL per hour).
MANAGEMENT
IMMEDIATE MANAGEMENT
SHOUT FOR HELP. Urgently mobilize all available personnel.
Monitor vital signs (pulse, blood pressure, respiration,
temperature).
S-2 Shock
If the woman is unconscious, turn her onto her side to minimize

the risk of aspiration if she vomits, and to ensure that an airway is
open.
Keep the woman warm but do not overheat her, as this will
increase peripheral circulation and reduce blood supply to the vital
centres.
Elevate the legs to increase return of blood to the heart (if possible,
raise the foot end of the bed).
SPECIFIC MANAGEMENT
Start an IV infusion (two if possible) using a large-bore (16-gauge
or largest available) cannula or needle. Collect blood for estimation
of haemoglobin, immediate cross-match and bedside clotting test
(see below), just before infusion of fluids:
Rapidly infuse IV fluids (normal saline or Ringer's lactate)
initially at the rate of 1 L in 15-20 minutes;
Note: Avoid using plasma substitutes (e.g. dextran). There is
no evidence that plasma substitutes are superior to normal
saline in the resuscitation of a shocked woman, and dextran
can be harmful in large doses.
Give at least 2 L of these fluids in the first hour. This is over
and above fluid replacement for ongoing losses.
Note: A more rapid rate of infusion is required in the
management of shock resulting from bleeding. Aim to replace
two to three times the estimated fluid loss.
Do not give fluids by mouth to a woman in shock.
If a peripheral vein cannot be cannulated, perform a venous cut-

down (Fig S-1).
Continue to monitor vital signs (every 15 minutes) and blood loss.
Catheterize the bladder and monitor fluid intake and urine output.
BEDSIDE CLOTTING TEST

Assess clotting status using this bedside clotting test:
Shock S-3
Take 2 mL of venous blood into a small, dry, clean, plain glass

test tube (approximately 10 mm x 75 mm);
Hold the tube in a closed fist to keep it wann (± 37°C);
After four minutes, tip the tube slowly to see if a clot is
forming. Then tip it again every minute until the blood clots
and the tube can be turned upside down;
Failure of a clot to form after seven minutes or a soft clot that
breaks down easily suggests coagulopathy (page S-19).
FIGURES-I Venous cut-down
Great
saphenous vein
Small
saphenous vein
A. Palpate and B. Infiltrate skin with

locate vein local anaesthetic
C. Makea2cm D. Expose the vein E. Insert sutures loosely

transverse under proximal and
incision distal end of vein
and tie distal suture
F. Make small G. Expose the vein and H. Tie upper suture to

incision in vein insert cannula secure cannula
I. Close the wound

. ~.
J. Secure cannula
with suture
S-4 Shock
DETERMINING AND MANAGING THE CAUSE OF SHOCK

Determine the cause of shock after the woman is stabilized.
If heavy bleeding is suspected as the cause of shock:
Take steps simultaneously to stop bleeding (e.g. oxytocics,
uterine massage, bimanual compression, aortic compression,
preparations for surgical intervention);
Transfuse as soon as possible to replace blood loss (page C-23);
Determine the cause of bleeding and manage accordingly:
If bleeding occurs during first 22 weeks of pregnancy,
suspect abortion, ectopic or molar pregnancy (page S-7);
If bleeding occurs after 22 weeks or during labour but
before delivery, suspect placenta praevia, abruptio
placentae or ruptured uterus (page S-17);
If bleeding occurs after childbirth, suspect ruptured
uterus, uterine atony, tears of genital tract, retained
placenta or placental fragments (page S-25).
Reassess the woman's condition for signs of improvement
(page S-5).
• If infection is suspected as the cause of shock:
Collect appropriate samples (blood, urine, pus) for microbial
culture before starting antibiotics, if facilities are available;
Give the woman a combination of antibiotics to cover aerobic
and anaerobic infections and continue until she is fever-free
for 48 hours (page C-35):
penicillin G 2 million units OR ampicillin 2 g IV every
six hours;
PLUS gentamicin 5 mg/kg body weight IV every 24
hours;
Do not give antibiotics by mouth to a woman in shock.
Reassess the woman's condition for signs of improvement

(page S-5).
Shock S-5
If trauma is suspected as the cause of shock, prepare for surgical

intervention.
REASSESSMENT
• Reassess the woman's response to fluids within 30 minutes to
determine if her condition is improving. Signs of improvement
include:
stabilizing pulse (rate of 90 per minute or less);
increasing blood pressure (systolic 100 mm Hg or more);
improving mental status (less confusion or anxiety);
increasing urine output (30 rnL per hour or more).
If the woman's condition improves:
Adjust the rate of infusion ofiV fluids to 1 L in six hours;
Continue management for the underlying cause of shock (page
S-4).
If the woman's condition fails to improve or stabilize, provide
further management (see below).
FURTHER MANAGEMENT
Continue to infuse IV fluids, adjusting the rate of infusion to 1 L in
six hours and maintain oxygen at 6-8 L per minute.
Closely monitor the woman's condition.
• Perform laboratory tests including repeat haemoglobin
determination, blood grouping and Rh typing. If facilities are
available, check serum electrolytes, serum creatinine and blood
pH.
S-6 Shock
VAGINAL BLEEDING IN EARLV PREGNANCY 5-7
PROBLEM
Vaginal bleeding occurs during the first 22 weeks of pregnancy.
GENERAL MANAGEMENT
Perform a rapid evaluation of the general condition of the woman,
temperature).
If the woman is in shock, consider ruptured ectopic pregnancy
(Table S-4, page S-14).
Start an IV infusion and infuse IV tluids (page C-21).
DIAGNOSIS
• Consider ectopic pregnancy in any woman with anaemia, pelvic
inflammatory disease (PID), threatened abortion or unusual
complaints about abdominal pain.
Note: If ectopic pregnancy is suspected, perform bimanual
examination gently because an early ectopic pregnancy is easily
ruptured.
Consider abortion in any woman of reproductive age who has a
missed period (delayed menstrual bleeding with more than one
month having passed since her last menstrual period) and has one
or more of the following: bleeding, cramping, partial expulsion of
products of conception, dilated cervix or smaller uterus than
expected.
• If abortion is a possible diagnosis, identify and treat any
complications immediately (Table S-2, page S-9).
S-8 Vaginal bleeding in early pregnancy
TABLES-1 Diagnosis of vaginal bleeding in early pregnancy
Presenting Symptom and Symptoms and Signs Probable Diagnosis

Other Symptoms and Signs Sometimes Present
Typically Present
• Light• bleeding • Cramping/lower Threatened
• Closed cervix abdominal pain abortion, page S-10
• Uterus corresponds to dates • Uterus softer than normal
• Light bleeding • Fainting Ectopic pregnancy
• Abdominal pain • Tender adnexal mass (Table S-4, page
• Closed cervix • Amenorrhoea S-14)
• Uterus slightly larger than • Cervical motion
normal tenderness
• Uterus softer than normal
• Light bleeding • Light cramping/lower Complete abortion,
• Closed cervix abdominal pain page S-12
• Uterus smaller than dates • History of expulsion of
• Uterus softer than normal products of conception
• Heavyb bleeding • Cramping/lower Inevitable abortion,
• Dilated cervix abdominal pain page S-11
• Uterus corresponds to dates • Tender uterus
• No expulsion of products
of conception
• Heavy bleeding • Cramping/lower Incomplete
• Dilated cervix abdominal pain abortion, page S-11
• Uterus smaller than dates • Partial expulsion of
products of conception
• Heavy bleeding • Nausea/vomiting Molar pregnancy,
• Dilated cervix • Spontaneous abortion page S-15
• Uterus larger than dates • Cramping/lower
• Uterus softer than normal abdominal pain
• Partial expulsion of products• Ovarian cysts (easily
of conception which ruptured)
resemble grapes • Early onset pre-eclampsia
• No evidence of a fetus
• Light bleeding: takes five minutes or longer for a clean pad or cloth to be soaked.
b Heavy bleeding: takes less than five minutes for a clean pad or cloth to be soaked.
TABLE S-2 Diagnosis and management of complications of

abortion
Symptoms and Signs Complication Management

• Lower abdominal pain Infection/sepsis Begin antibiotics• as
• Rebound tenderness soon as possible before
• Tender uterus attempting manual
• Prolonged bleeding vacuum aspiration
• Malaise (page P-65).
• Fever
• Foul-smelling vaginal
discharge
• Purulent cervical discharge
• Cervical motion tenderness
• Cramping/abdominal pain Uterine, vaginal Perform a laparotomy to
• Rebound tenderness or bowel injuries repair the injury and
• Abdominal distension perform manual vacuum
• Rigid (tense and hard) aspiration (page P-65)
abdomen simultaneously. Seek
• Shoulder pain further assistance if
• Nausea/vomiting required.
• Fever
• Give ampicillin 2 g IV every six hours PLUS gentamicin 5 mg/kg body weight IV
every 24 hours PLUS metronidazole 500 mg IV every eight hours until the woman
is fever-free for 48 hours (page C-35).
BOXS-1 Types of abortion
Spontaneous abortion is defined as the loss of a pregnancy before fetal

viability (22 weeks gestation). The stages of spontaneous abortion may
include:
threatened abortion (pregnancy may continue);
inevitable abortion (pregnancy will not continue and will
proceed to incomplete/complete abortion);
incomplete abortion (products of conception are partially
expelled);
complete abortion (products of conception are completely
expelled).
Induced abortion is defined as a process by which pregnancy is
terminated before fetal viability.
Unsafe abortion is defined as a procedure performed either by persons

lacking necessary skills or in an environment lacking minimal medical
standards, or both.
Septic abortion is defined as abortion complicated by infection. Sepsis

may result from infection if organisms rise from the lower genital tract
following either spontaneous or unsafe abortion. Sepsis is more likely to
occur if there are retained products of conception and evacuation has
been delayed. Sepsis is a frequent complication of unsafe abortion
involving instrumentation.
MANAGEMENT
If unsafe abortion is suspected, examine for signs of infection

or uterine, vaginal or bowel injury (Table S-2, page S-9), and
thoroughly irrigate the vagina to remove any herbs, local
medications or caustic substances.
THREATENED ABORTION
Medical treatment is usually not necessary.
Advise the woman to avoid strenuous activity and sexual
intercourse, but bed rest is not necessary.
If bleeding stops, follow up in antenatal clinic. Reassess if

bleeding recurs.
• If bleeding persists, assess for fetal viability (pregnancy
test/ultrasound) or ectopic pregnancy (ultrasound). Persistent
bleeding, particularly in the presence of a uterus larger than
expected, may indicate twins or molar pregnancy.
Do not give medications such as hormones (e.g. oestrogens or

progestins) or tocolytic agents (e.g. salbutamol or
indomethacin), as they will not prevent miscarriage.
INEVITABLE ABORTION
If pregnancy is less than 16 weeks, plan for evacuation of uterine
contents (page P-65). If evacuation is not immediately possible:
Give ergometrine 0.2 mg IM (repeated after 15 minutes if
necessary) OR misoprostol400 mcg by mouth (repeated once
after four hours if necessary);
Arrange for evacuation of uterus as soon as possible.
If pregnancy is greater than 16 weeks:
A wait spontaneous expulsion of products of conception and
then evacuate the uterus to remove any remaining products of
conception (page P-65);
If necessary, infuse oxytocin 40 units in 1 L IV fluids (normal
saline or Ringer's lactate) at 40 drops per minute to help
achieve expulsion of products of conception.
Ensure follow-up of the woman after treatment (page S-12).
INCOMPLETE ABORTION
If bleeding is light to moderate and pregnancy is less than 16
weeks, use fingers or ring (or sponge) forceps to remove products
of conception protruding from the cervix.
• If bleeding is heavy and pregnancy is less than 16 weeks,
evacuate the uterus:
Manual vacuum aspiration is the preferred method of
evacuation (page P-65). Evacuation by sharp curettage should
only be done if manual vacuum aspiration is not available

(page P-61);
If evacuation is not immediately possible, give ergometrine
0.2 mg IM (repeated after 15 minutes if necessary) OR
misoprostol 400 mcg orally (repeated once after four hours if
necessary).
If pregnancy is greater than 16 weeks:
Infuse oxytocin 40 units in 1 L IV fluids (normal saline or
Ringer's lactate) at 40 drops per minute until expulsion of
products of conception occurs;
If necessary, give misoprostol200 mcg vaginally every four
hours until expulsion, but do not administer more than 800
mcg;
Evacuate any remaining products of conception from the
uterus (page P-65).
• Ensure follow-up of the woman after treatment (see below).
COMPLETE ABORTION
• Evacuation of the uterus is usually not necessary.
Observe for heavy bleeding.
Ensure follow-up of the woman after treatment (see below).
FOLLOW-UP OF WOMEN WHO HAVE HAD AN ABORTION

Before discharge, tell a woman who has had a spontaneous abortion
that spontaneous abortion is common and occurs in at least 15% (one in
every seven) of clinically recognized pregnancies. Also reassure the
woman that the chances for a subsequent successful pregnancy are
good unless there has been sepsis or a cause of the abortion is identified
that may have an adverse effect on future pregnancies (this is rare).
Some women may want to become pregnant soon after having an
incomplete abortion. The woman should be encouraged to delay the
next pregnancy until she is completely recovered.
It is important to counsel women who have had an unsafe abortion. If
pregnancy is not desired, certain methods of family planning (Table
S-3, page S-13) can be started immediately (within seven days)
provided:
There are no severe complications requiring further treatment;

• The woman receives adequate counselling and help in selecting the
most appropriate family planning method.
TABLE S-3 Family planning methods
Type of Contraceptive Advise to Start

Hormonal (pills, injections, • Immediately
implants)
Condoms • Immediately
Intrauterine device (IUD) • Immediately
• If infection is present or suspected, delay
insertion until it is cleared
• If Hb is less than 7 g/dL, delay until anaemia
improves
• Provide an interim method (e.g. condom)
Voluntary tuballigation • Immediately
• If infection is present or suspected, delay
surgery until it is cleared
• If Hb is less than 7 g/dL, delay until anaemia
improves
• Provide an interim method (e.g. condom)
Identify any other reproductive health services that a woman may need.
For example some women may need:
• tetanus prophylaxis or tetanus booster;
• treatment for sexually transmitted infections (STis);
cervical cancer screening.
ECTOPIC PREGNANCY
An ectopic pregnancy is one in which implantation occurs outside the
uterine cavity. The fallopian tube is the most common site of ectopic
implantation (greater than 90% ).
Symptoms and signs are extremely variable depending on whether or
not the pregnancy has ruptured (Table S-4, page S-14). Culdocentesis
(cul-de-sac puncture, page P-69) is an important tool for the diagnosis
of ruptured ectopic pregnancy, but is less useful than a serum
pregnancy test combined with ultrasonography. If non-clotting blood
is obtained, begin immediate management.
TABLE S-4 Symptoms and signs of ruptured and

unruptured ectopic pregnancy
Unruptured Ectopic Pregnancy Ruptured Ectopic Pregnancy

• Symptoms of early pregnancy • Collapse and weakness
(irregular spotting or bleeding, • Fast, weak pulse (110 per minute or
nausea, swelling of breasts, bluish more)
discoloration of vagina and cervix, • Hypotension
softening of cervix, slight uterine • Hypovolaemia
enlargement, increased urinary • Acute abdominal and pelvic pain
frequency) • Abdominal distension•
• Abdominal and pelvic pain • Rebound tenderness
• Pallor
a Distended abdomen with shifting dullness may indicate free blood.
DIFFERENTIAL DIAGNOSIS
The most common differential diagnosis for ectopic pregnancy is
threatened abortion. Others are acute or chronic PID, ovarian cysts
(torsion or rupture) and acute appendicitis.
If available, ultrasound may help distinguish a threatened abortion or
twisted ovarian cyst from an ectopic pregnancy.
Cross-match blood and arrange for immediate laparotomy. Do not
wait for blood before performing surgery.
At surgery, inspect both ovaries and fallopian tubes:
If there is extensive damage to the tubes, perform
salpingectomy (the bleeding tube and the products of
conception are removed together). This is the treatment of
choice in most cases (page P-109);
Rarely, if there is little tubal damage, perform salpingostomy
(the products of conception can be removed and the tube
conserved). This should be done only when the conservation
of fertility is very important to the woman, as the risk of
another ectopic pregnancy is high (page P-111).
AUTOTRANSFUSION
If significant haemorrhage occurs, avtotransfusion can be used if the
blood is unquestionably fresh and free from infection (in later stages
of pregnancy, blood is contaminated [e.g. with amniotic fluid] and
should not be used for autotransfusion). The blood can be collected
prior to surgery or after the abdomen is opened:
Vaginal bleeding in early pregnancy 8-15
• When the woman is on the operating table prior to surgery and the
abdomen is distended with blood, it is sometimes possible to insert
a needle through the abdominal wall and collect the blood in a
donor set.
• Alternatively, open the abdomen:
Scoop the blood into a basin and strain through gauze to
remove clots;
Clean the top portion of a blood donor bag with antiseptic
solution and open it with a sterile blade;
Pour the woman's blood into the bag and reinfuse it through a
filtered set in the usual way;
If a donor bag with anticoagulant is not available, add
sodium citrate 10 mL to each 90 mL of blood.
SUBSEQUENT MANAGEMENT
Prior to discharge, provide counselling and advice on prognosis for
fertility. Given the increased risk of future ectopic pregnancy,
family planning counselling and provision of a family planning
method, if desired, is especially important (Table S-3, page S-13).
• Correct anaemia with ferrous sulfate or ferrous fumerate 60 mg by
mouth daily for six months.
• Schedule a follow-up visit at four weeks.
MOLAR PREGNANCY
Molar pregnancy is characterized by an abnormal proliferation of
chorionic villi.
If the diagnosis of molar pregnancy is certain, evacuate the
uterus:
If cervical dilatation is needed, use a paracervical block
(page P-1);
Use vacuum aspiration (page P-65). Manual vacuum
aspiration is safer and associated with less blood loss. The risk
of perforation using a metal curette is high;
Have three syringes cocked and ready for use during the
evacuation. The uterine contents are copious and it is
important to evacuate them rapidly.
Infuse oxytocin 20 units in 1 L IV fluids (normal saline or Ringer's
lactate) at 60 drops per minute to prevent haemorrhage once
evacuation is under way.
SUBSEQUENT MANAGEMENT
Recommend a hormonal family planning method for at least one
year to prevent pregnancy (Table S-3, page S-13). Voluntary tubal
ligation may be offered if the woman has completed her family.
Follow up every eight weeks for at least one year with urine
pregnancy tests because of the risk of persistent trophoblastic
disease or choriocarcinoma. If the urine pregnancy test is not
negative after eight weeks or becomes positive again within the
first year, urgently refer the woman to a tertiary care centre for
further follow-up and management of choriocarcinoma.
VAGINAL BLEEDING IN LATER PREGNANCY s-11
AND LABOUR
PROBLEMS
Vaginal bleeding after 22 weeks of pregnancy.
• Vaginal bleeding in labour before delivery.
TABLE S-S Types of bleeding
Type of Bleeding Probable Diagnosis Action

Blood-stained mucus Onset of labour Proceed with
(show) management of normal
labour and childbirth,
page C-57
Any other bleeding Antepartum Determine cause (Table
haemorrhage S-6, page S-18)
GENERAL MANAGEMENT
temperature).
Do not do a vaginal examination at this stage.

Start an IV infusion and infuse IV fluids (page C-21).
S-18 Vaginal bleeding in later pregnancy and labour
DIAGNOSIS
TABLES-6 Diagnosis of antepartum haemorrhage

Typically Present
o Bleeding after 22 weeks o Shock Abruptio placentae,
gestation (may be retained in o Tense/tender uterus page S-18
the uterus) o Decreased/absent fetal
o Intermittent or constant movements
abdominal pain o Fetal distress or absent
fetal heart sounds
o Bleeding (intra-abdominal o Shock Ruptured uterus,
and/or vaginal) o Abdominal distension/ page S-20
o Severe abdominal pain (may free fluid
decrease after rupture) o Abnormal uterine contour
o Tender abdomen
o Easily palpable fetal parts
o Absent fetal movements
and fetal heart sounds
o Rapid maternal pulse
o Bleeding after 22 weeks o Shock Placenta praevia,
gestation o Bleeding may be page S-21
precipitated by intercourse
o Relaxed uterus
o Fetal presentation not in
pelvisnower uterine pole
feels empty
o Normal fetal condition
MANAGEMENT
ABRUPTIO PLACENTAE
Abruptio placentae is the detachment of a normally located placenta
from the uterus before the fetus is delivered.
Assess clotting status using a bedside clotting test (page S-2).
• Transfuse as necessary, preferably with fresh blood (page C-23).
• If bleeding is heavy (evident or hidden), deliver as soon as

possible:
If the cervix is fully dilated, deliver by vacuum extraction
(page P-27);
If vaginal delivery is not imminent, deliver by caesarean
section (page P-43).
Note: In every case of abruptio placentae, be prepared for
postpartum haemorrhage (page S-25).
If bleeding is light to moderate (the mother is not in immediate
danger), the course of action depends on the fetal heart rate:
If fetal heart rate is normal or absent, rupture the
membranes with an amniotic hook or a Kocher clamp (page
P-17):
If contractions are poor, augment labour with oxytocin
(page P-25);
If the cervix is unfavourable (firm, thick, closed),
perform caesarean section (page P-43).
If fetal heart rate is abnormal (less than 100 or more than
180 beats per minute):
Perform rapid vaginal delivery;
If vaginal delivery is not possible, deliver by immediate
caesarean section (page P-43).
COAGULOPATHY (CLOTTING FAILURE)

Coagulopathy is both a cause and a result of massive obstetric
haemorrhage. It can be triggered by abruptio placentae, fetal death in-
utero, eclampsia, amniotic fluid embolism and many other causes. The
clinical picture ranges from major haemorrhage, with or without
thrombotic complications, to a clinically stable state that can be
detected only by laboratory testing.
Note: In many cases of acute blood loss, the development of
coagulopathy can be prevented if blood volume is restored promptly by
infusion ofiV fluids (normal saline or Ringer's lactate).
Treat the possible cause of coagulation failure:
abruptio placentae (page S-18);
eclampsia (page S-43).
Use blood products to help control haemorrhage (page C-23):

Give fresh whole blood, if available, to replace clotting factors
and red cells;
If fresh whole blood is not available, choose one of the
following based on availability:
fresh frozen plasma for replacement of clotting factors (15
mL/kg body weight);
packed (or sedimented) red cells for red cell replacement;
cryoprecipitate to replace fibrinogen;
platelet concentrates (if bleeding continues and the
platelet count is less than 20 000).
RUPTURED UTERUS
Bleeding from a ruptured uterus may occur vaginally unless the fetal
head blocks the pelvis. Bleeding may also occur intra-abdominally.
Rupture of the lower uterine segment into the broad ligament, however,
will not release blood into the abdominal cavity (Fig S-2).
FIGURES-2 Rupture of lower uterine segment into broad
ligament will not release blood into the abdominal
cavity
Haematoma in
broad ligament
Restore blood volume by infusing IV fluids (normal saline or

Ringer's lactate) before surgery.
When stable, immediately perform caesarean section and deliver
baby and placenta (page P-43).
If the uterus can be repaired with less operative risk than
hysterectomy would entail and the edges of the tear are not
necrotic, repair the uterus (page P-95). This involves less time and
blood loss than hysterectomy.
Because there is an increased risk of rupture with subsequent

pregnancies, the option of permanent contraception needs to
be discussed with the woman after the emergency is over.
If the uterus cannot be repaired, perform subtotal hysterectomy

(page P-103). If the tear extends through the cervix and vagina,
total hysterectomy may be required.
PLACENTA PRAEVIA
Placenta praevia is implantation of the placenta at or near the cervix
(Fig S-3).
FIGURES-3 Implantation of the placenta at or near the cervix.
A. Low placental B. Partial placenta C. Complete

implantation praevia placenta praevia
Warning: Do not perform a vaginal examination unless

preparations have been made for immediate caesarean section. A
careful speculum examination may be performed to rule out other
causes of bleeding such as cervicitis, trauma, cervical polyps or cervical
malignancy. The presence of these, however, does not rule out placenta
praevia.
Restore blood volume by infusing IV fluids (normal saline or
Ringer's lactate).
Assess the amount of bleeding:
If bleeding is heavy and continuous, arrange for caesarean
delivery irrespective of fetal maturity (page P-43);
If bleeding is light or if it has stopped and the fetus is alive

but premature, consider expectant management until delivery
or heavy bleeding occurs:
Keep the woman in the hospital until delivery;
Correct anaemia with ferrous sulfate or ferrous fumerate
60 mg by mouth daily for six months;
Ensure that blood is available for transfusion, if required;
If bleeding recurs, decide management after weighing
benefits and risks for the woman and fetus of further
expectant management versus delivery.
CONFIRMING THE DIAGNOSIS

If a reliable ultrasound examination can be performed, localize
the placenta. If placenta praevia is confirmed and the fetus is
mature, plan delivery (page S-23).
If ultrasound is not available or the report is unreliable and the
pregnancy is less than 37 weeks, manage as placenta praevia until
37 weeks.
If ultrasound is not available or the report is unreliable and the
pregnancy is 37 weeks or more, examine the woman and be
prepared for either vaginal or caesarean delivery, as follows:
have IV lines running and cross-matched blood available;
exam the woman in the operating theatre with the surgical
team present;
use a high-level disinfected vaginal speculum to examine the
cervix.
If the cervix is partly dilated and placental tissue is visible
(placenta praevia is confirmed), plan delivery (page S-23).
If the cervix is not dilated, cautiously palpate the vaginal fornices:
If spongy tissue is felt (placenta praevia is confirmed), plan
delivery (page S-23);
If a firm fetal head is felt (major placenta praevia is ruled
out), proceed to deliver by induction (page P-18).
If a diagnosis of placenta praevia is still in doubt, perform a
cautious digital examination:
Vaginal bleeding in later pregnancy and labour 5-23
If soft tissue is felt within the cervix (placenta praevia is

confirmed), plan delivery (below);
If membranes and fetal parts are felt both centrally and
marginally (placenta praevia is ruled out), proceed to deliver
by induction (page P-17).
DELIVERY
• Plan delivery if:
the fetus is mature;
the fetus is dead or has an anomaly not compatible with life
(e.g. anencephaly);
the woman's life is at risk because of excessive blood loss.
If there is low placental implantation (Fig S-3 A) and bleeding is
light, vaginal delivery may be possible. Otherwise, deliver by
Note: Women with placenta praevia are at high risk for postpartum
haemorrhage and placenta accreta/increta, a common finding at the
site of a previous caesarean scar.
If delivered by caesarean section and there is bleeding from the
placental site:
Under-run the bleeding sites with sutures;
Infuse oxytocin 20 units in 1 L IV fluids (normal saline or
Ringer's lactate) at 60 drops per minute.
If bleeding occurs during the postpartum period, initiate
appropriate management (page S-25). This may include artery
ligation (page P-99) or hysterectomy (page P-103).
S·24 Vaginal bleeding in later pregnancy and labour
VAGINAL BLEEDING AFTER CHILDBIRTH S-25
Vaginal bleeding in excess of 500 mL after childbirth is defined as

postpartum haemorrhage (PPH). There are, however, some problems
with this definition:
• Estimates of blood loss are notoriously low, often half the actual
loss. Blood is mixed with amniotic fluid and sometimes with urine.
It is dispersed on sponges, towels and linens, in buckets and on the
floor.
The importance of a given volume of blood loss varies with the
woman's haemoglobin level. A woman with a normal haemoglobin
level will tolerate blood loss that would be fatal for an anaemic
woman.
Even healthy, non-anaemic women can have catastrophic

blood loss.
Bleeding may occur at a slow rate over several hours; the condition
may not be recognized until the woman suddenly enters shock.
Risk assessment in the antenatal period does not effectively predict

those women who will have PPH. Active management of the third
stage should be practised on all women in labour because it reduces
the incidence of PPH due to uterine atony (page C-73). All
postpartum women must be closely monitored to determine those who
have PPH.
PROBLEMS
Increased vaginal bleeding within the first 24 hours after childbirth
(immediate PPH).
Increased vaginal bleeding following the first 24 hours after
childbirth (delayed PPH).
Continuous slow bleeding or sudden bleeding is an

emergency; intervene early and aggressively.
S-26 Vaginal bleeding after childbirth
GENERAL MANAGEMENT
temperature).
Massage the uterus to expel blood and blood clots. Blood clots
trapped in the uterus will inhibit effective uterine contractions.
Give oxytocin 10 units IM.
• Catheterize the bladder.
• Check to see if the placenta has been expelled, and examine the
placenta to be certain it is complete (Table S-7, page S-27).
• Examine the cervix, vagina and perineum for tears.
• Check for anaemia afte~; bleeding has been stopped for 24 hours:
If haemoglobin is less than 7 gldL or haematocrit is less
than 20% (severe anaemia) arrange for a transfusion (page
C-23) and give oral iron and folic acid:
Give ferrous sulfate or ferrous fumerate 120 mg by mouth
PLUS folic acid 400 mcg by mouth once daily for three
months;
After three months, continue supplementation with ferrous
sulfate or ferrous fumerate 60 mg by mouth PLUS folic
acid 400 mcg by mouth once daily for six months.
If haemoglobin is 7-11 gldL, give ferrous sulfate or ferrous
fumerate 60 mg by mouth PLUS folic acid 400 mcg by mouth
once daily for six months;
Where hookworm is endemic (prevalence of 20% or more),
give one of the following anthelmintic treatments:
albendazole 400 mg by mouth once;
OR mebendazole 500 mg by mouth once or 100 mg two
times per day for three days;
OR levamisole 2.5 mg/kg body weight by mouth once

daily for three days;
OR pyrantel 10 mg/kg body weight by mouth once daily
for three days.
If hookworm is highly endemic (prevalence of 50% or more),
repeat the anthelmintic treatment 12 weeks after the first dose.
DIAGNOSIS
TABLE S-7 Diagnosis of vaginal bleeding after childbirth

Typically Present
• Immediate PPHa • Shock Atonic uterus, page
• Uterus soft and not S-28
contracted
• Immediate PPH" • Complete placenta Tears of cervix, vagina
• Uterus contracted or perineum, page S-31
• Placenta not delivered within • Immediate PPHa Retained placenta,
30 minutes after delivery • Uterus contracted page S-31
• Portion of maternal surface • Immediate PPHa Retained placental
of placenta missing or torn • Uterus contracted fragments, page S-32
membranes with vessels
• Uterine fundus not felt on • Inverted uterus Inverted uterus, page
abdominal palpation apparent at vulva S-33
• Slight or intense pain • Immediate PPHb
• Bleeding occurs more than • Bleeding is variable Delayed PPH, page
24 hours after delivery (light or heavy, S-33
• Uterus softer and larger than continuous or
expected for elapsed time irregular) and foul-
since delivery smelling
• Anaemia
• Immediate PPH" (bleeding is • Shock Ruptured uterus, page
intra-abdominal and/or • Tender abdomen S-20
vaginal) • Rapid maternal pulse
• Severe abdominal pain (may
decrease after rupture)
a Bleeding may be light if a clot blocks the cervix or if the woman is lying on her
back.
b There may be no bleeding with complete inversion.
5·28 Vaginal bleeding after childbirth
MANAGEMENT
ATONIC UTERUS
An atonic uterus fails to contract after delivery.
Continue to massage the uterus.
Use oxytocic drugs which can be given together or sequentially
(Table S-8).
TABLES-8 Use of oxytocic drugs
Dose and Continuing Maximum Precautions

Route Dose Dose and
Contra-
Indications
Oxytocin IV: Infuse IV: Infuse Not more Do not give
20 units in 20 units in than 3 L of as an IV
1 LIV 1 L IV IV fluids bolus
fluids at 60 fluids at 40 containing
drops per drops per oxytocin
minute minute
IM: 10 units
Ergometrine/ IM or IV Repeat0.2 Five doses High blood
Methyl- (slowly): 0.2 mg IM after (Total1.0 pressure,
ergometrine mg 15 minutes. mg) pre-
If required, eclampsia,
give0.2 mg heart disease
IMoriV
(slowly)
every four
hours
15-Methyl IM: 0.25 mg 0.25 mg Eight doses Asthma
Prostaglandi every 15 (Total2 mg)
nF2 minutes
Prostaglandins should not be given intravenously. They may

be fatal.
Anticipate the need for blood early, and transfuse as necessary

(page C-23).
If bleeding continues:
Check placenta again for completeness;
If there are signs of retained placental fragments (absence of
a portion of maternal surface or torn membranes with vessels),
remove remaining placental tissue (page S-32);
Assess clotting status using a bedside clotting test (page S-2).
If bleeding continues in spite of management above:
Perform bimanual compression of the uterus (Fig S-4):
Wearing high-level disinfected or sterile gloves, insert a
hand into the vagina and remove any blood clots from the
lower part of the uterus or cervix;
Form a fist;
Place the fist into the anterior fornix and apply pressure
against the anterior wall of the uterus;
With the other hand, press deeply into the abdomen
behind the uterus, applying pressure against the posterior
wall of the uterus;
Maintain compression until bleeding is controlled and the
uterus contracts.
FIGURE S-4 Bimanual compression of the uterus
Alternatively, compress the aorta (Fig S-5):

Apply downward pressure with a closed fist over the
abdominal aorta directly through the abdominal wall:
The point of compression is just above the umbilicus
and slightly to the left;
Aortic pulsations can be felt easily through the
anterior abdominal wall in the immediate postpartum
period.
With the other hand, palpate the femoral pulse to check
the adequacy of compression:
If the pulse is palpable during compression, the
pressure exerted by the fist is inadequate;
If the femoral pulse is not palpable, the pressure
exerted is adequate;
Maintain compression until bleeding is controlled.
FIGURES-5 Compression of abdominal aorta and palpation of
femoral pulse
Packing the uterus is ineffective and wastes precious time.

If bleeding continues in spite of compression:

Perform uterine and utero-ovarian artery ligation (page P-99);
If life-threatening bleeding continues after ligation, perform
subtotal hysterectomy (page P-103).
TEARS OF CERVIX, VAGINA OR PERINEUM

Tears of the birth canal are the second most frequent cause of PPH.
Tears may coexist with atonic uterus. Postpartum bleeding with a
contracted uterus is usually due to a cervical or vaginal tear.
Examine the woman carefully and repair tears to the cervix (page
P-81) or vagina and perineum (page P-83).
If bleeding continues, assess clotting status using a bedside
clotting test (page S-2). Failure of a clot to form after seven
minutes or a soft clot that breaks down easily suggests
coagulopathy (page S-19).
RETAINED PLACENTA
There may be no bleeding with retained placenta.
Apply controlled cord traction to remove the placenta.

Note: Avoid forceful cord traction and fundal pressure, as they
may cause uterine inversion.
If the placenta is not expelled, give oxytocin 10 units IM if not
already done for active management of the third stage.
Do not give ergometrine for retained placenta because it

causes tonic uterine contraction, which may delay expulsion.
Ensure that the bladder is empty. Catheterize the bladder, if

necessary.
If the placenta is undelivered after 30 minutes of oxytocin
stimulation and controlled cord traction, attempt manual removal
of the placenta (page P-77).
Note: Very adherent tissue may be placenta accreta. Efforts to
extract a placenta that does not separate easily may result in heavy
bleeding or uterine perforation, which usually requires

hysterectomy.
• If bleeding continues, assess clotting status using a bedside
If there are signs of infection (fever, foul-smelling vaginal
discharge), give antibiotics as for metritis (page S-110).
RETAINED PLACENTAL FRAGMENTS
There may be no bleeding with retained placental fragments.
When a portion of the placenta--<Jne or more lobes-is retained, it

prevents the uterus from contracting effectively.
• Feel inside the uterus for placental fragments. Manual exploration
of the uterus is similar to the technique described for removal of
the retained placenta (page P-77).
Remove placental fragments by hand, ovum forceps or wide
curette (page {).
Note: Very adherent tissue may be placenta accreta. Efforts to
extract fragments that do not separate easily may result in heavy
bleeding or uterine perforation which usually requires
hysterectomy.
INVERTED UTERUS
The uterus is said to be inverted if it turns inside-out during delivery of
the placenta. Repositioning the uterus should be performed immediately
(page P-91). With the passage of time the constriction ring around the
inverted uterus becomes more rigid and the uterus more engorged with
blood.
If the woman is in severe pain, give pethidine 1 mg/kg body
weight (but not more than 100 mg) IM or IV slowly or give
morphine 0.1 mg/kg body weight IM.
Note: Do not give oxytocic drugs until the inversion is corrected.
Give a single dose of prophylactic antibiotics after correcting the
inverted uterus (page C-35):
ampicillin 2 g IV PLUS metronidazole 500 mg IV;
OR cefazolin 1 g IV PLUS metronidazole 500 mg IV.
If necrosis is suspected, perform vaginal hysterectomy. This may
require referral to a tertiary care centre.
DELAYED ("SECONDARY") POSTPARTUM HAEMORRHAGE

If anaemia is severe (haemoglobin less than 7 g/dL or haematocrit
less than 20% ), arrange for a transfusion (page C-23) and provide
oral iron and folic acid (page S-26).
Prolonged or delayed PPH may be a sign of metritis.
Give oxytocic drugs (Table S-8, page S-28).

If the cervix is dilated, explore by hand to remove large clots and
placental fragments. Manual exploration of the uterus is similar to
the technique described for removal of the retained placenta (page

P-77).
If the cervix is not dilated, evacuate the uterus to remove placental
fragments (page P-65).
Rarely, if bleeding continues, consider uterine and utero-ovarian
artery ligation (page P-99) or hysterectomy (page P-103).
Perform histopathologic examination of curettings or hysterectomy
specimen, if possible, to rule out trophoblastic tumour.
ELEVATED BLOOD PRESSURE, HEADACHE, s-as
BLURRED VISION, CONVULSIONS OR LOSS OF
CONSCIOUSNESS
PROBLEMS
A pregnant woman or a woman who recently delivered complains
of severe headache or blurred vision.
A pregnant woman or a woman who recently delivered is found
unconscious or having convulsions (seizures).
A pregnant woman has elevated blood pressure.
GENERAL MANAGEMENT
• If the woman is unconscious or convulsing, SHOUT FOR
HELP. Urgently mobilize all available personnel.
including vital signs (pulse, blood pressure, respiration) while
simultaneously finding out the history of her present and past
illnesses either from her or from her relatives.
If the woman is not breathing or her breathing is shallow:
Check airway and intubate if required;
If she is not breathing, assist ventilation using an Ambu bag
and mask or give oxygen at 4-6 L per minute by endotracheal
tube;
If she is breathing, give oxygen at 4-6 L per minute by mask
or nasal cannulae.
If the woman is unconscious:
Check airway and temperature;
Position her on her left side;
Check for neck rigidity.
If the woman is convulsing:
Position her on her left side to reduce the risk of aspiration of
secretions, vomit and blood;
Protect her from injuries (fall), but do not attempt to restrain
her;
S-36 Elevated blood pressure, headache, blurred vision, convulsions or loss of consciousness
Provide constant supervision;

If eclampsia is diagnosed (Table S-9, page S-38), give
magnesium sulfate (Box S-3, page S-45);
If the cause of convulsions has not been determined,
manage as eclampsia and continue to investigate other causes.
DIAGNOSIS OF HYPERTENSIVE DISORDERS

The hypertensive disorders of pregnancy include pregnancy-induced
hypertension and chronic hypertension (elevation of the blood pressure
before 20 weeks gestation). Headaches, blurred vision, convulsions and
loss of consciousness are often associated with hypertension in
pregnancy, but are not necessarily specific to it. Other conditions that
may cause convulsions or coma include epilepsy, complicated malaria,
head injury, meningitis, encephalitis, etc. See Table S-9, page S-38 for
more information on diagnosis.
Diastolic blood pressure is a good indicator of prognosis for the
management of hypertensive disorders in pregnancy:
Diastolic blood pressure is taken at the point at which the
arterial sound disappears:
A falsely high reading is obtained if the cuff does not
encircle at least three-fourths of the circumference of the
arm;
A wider cuff should be used when the diameter of the
upper arm is more than 30 cm;
Diastolic blood pressure measures peripheral resistance and
does not vary with the woman's emotional state to the degree
that systolic pressure does.
If the diastolic blood pressure is 90 mm Hg or more on two
consecutive readings taken four hours or more apart, diagnose
hypertension. If urgent delivery must take place or if the
diastolic blood pressure is 110 mm Hg or more, a time interval
of less than four hours is acceptable:
If hypertension occurs after 20 weeks of gestation, during
labour and/or within 48 hours of delivery it is classified as
pregnancy-induced hypertension;
If hypertension occurs before 20 weeks of gestation, it is
classified as chronic hypertension.
Headache, blurred vision, convulsions or loss of consciousness, elevated blood pressure S-37
PROTEINURIA
The presence of proteinuria changes the diagnosis from pregnancy-
induced hypertension to pre-eclampsia. Other conditions cause
proteinuria and false positive results are possible. Urinary infection,
severe anaemia, heart failure and difficult labour may all cause
proteinuria. Blood in the urine due to catheter trauma or schistosomiasis
and contamination from vaginal blood could give false positive results.
Random urine sampling, such as the dipstick test for protein, is a useful
screening tool. A change from negative to positive during pregnancy is
a warning sign. If dipsticks are not available, a sample of urine can be
heated to boiling in a clean test tube. Add a drop of 2% acetic acid to
check for persistent precipitates that can be quantified as a percentage
of protein to the volume of the total sample. Vaginal secretions or
amniotic fluid may contaminate urine specimens. Only clean-catch
mid-stream specimens should be used. Catheterization for this purpose
is not justified due to the risk of urinary tract infection.
Diastolic blood pressure alone is an accurate indicator of

hypertension in pregnancy. Elevated blood pressure and
proteinuria, however, define pre-eclampsia.
PREGNANCY-INDUCED HYPERTENSION
Women with pregnancy-induced hypertension disorders may progress
from mild disease to a more serious condition. The classes of
pregnancy-induced hypertension are:
hypertension without proteinuria;
mild pre-eclampsia;
severe pre-eclampsia;
eclampsia.
5·38 Elevated blood pressure, headache, blurred vision, convulsions or loss of consciousness
TABLES-9 Diagnosis of elevated blood pressure, headache,

blurred vision, convulsions or loss of consciousness

Typically Present
• Diastolic blood pressure 90 Chronic
mm Hg or more before first hypertension, page
20 weeks of ~estation S-49
• Diastolic blood pressure Chronic
90-110 mm Hg before 20 hypertension with
weeks of gestation superimposed mild
• Proteinuria up to 2+ pre-eclampsia, page
S-42
• Two readings of diastolic Pregnancy-induced
blood pressure 90-110 mm hypertension, page
Hg 4 hours apart after 20 S-41
weeks gestation
• No proteinuria
• Two readings of diastolic Mild pre-eclampsia,
blood pressure 90-IIO mm page S-42
Hg 4 hours apart after 20
weeks gestation
• Proteinuria up to 2+
• Diastolic blood pressure • Headache (increasing Severe pre-
110 mm Hg or more after frequency, unrelieved by eclampsia•, page S-43
20 weeks gestation regular analgesics)
• Proteinuria 3+ or more • Blurred vision
• Oliguria (passing less than
400 mL urine in 24 hours)
• Upper abdominal pain
(epigastric pain or pain in
right upper quadrant)
• Pulmon~ oedema
• Convulsions • Coma (unconscious) Eclampsia, page S-43
• Diastolic blood pressure 90 • Other symptoms and signs
mm Hg or more after 20 of severe pre-eclampsia
weeks gestation
• Proteinuria 2+ or more
• Trismus (difficulty opening • Spasms of face, neck, trunk Tetanus, pageS-50
mouth and chewing) • Arched back
• Board-like abdomen
• Spontaneous violent
s asms
• If a woman has any one of the symptoms or signs listed under severe pre-
eclampsia, diagnose severe pre-eclampsia.
TABLE S-9 Cont. Diagnosis of elevated blood pressure, headache,

blurred vision, convulsions or loss of consciousness

Typically Present
o Convulsions Epilepsy\ page S-51
o Past history of convulsions
o Normal blood pressure
o Fever o Enlarged spleen Uncomplicated
o Chills/rigors malaria, page S-103
o Headache
o Muscle/joint pain
o Symptoms and signs of o Convulsions Severe/complicated
uncomplicated malaria o Jaundice malaria, page S-52
o Coma
o Anaemia
o Headache o Convulsions Meningitisb,c or
o Stiffneck o Confusion Encephalitisb,c
o Photophobia o Drowsiness
o Fever o Coma
o Headache o Vomiting Migrained
o Blurred vision
b If a diagnosis of eclampsia cannot be ruled out, continue treatment for eclampsia.
c Examine cerebrospinal fluid and give appropriate treatment for meningitis or

encephalitis.
d Give analgesics (e.g. paracetamol 500 mg by mouth as needed).
A small proportion of women with eclampsia have normal

blood pressure. Treat all women with convulsions as if they
have eclampsia until another diagnosis is confirmed.
Remember:
Mild pre-eclampsia often has no symptoms.
Increasing proteinuria is a sign of worsening pre-eclampsia.
Oedema of the feet and lower extremities is not considered a
reliable sign of pre-eclampsia.
In pregnancy-induced hypertension, there may be no

symptoms and the only sign may be hypertension.
Mild pre-eclampsia may progress rapidly to severe pre-eclampsia.

The risk of complications, including eclampsia, increases greatly in
severe pre-eclampsia.
• Convulsions with signs of pre-eclampsia indicates eclampsia.
These convulsions:
can occur regardless of the severity of hypertension;
are difficult to predict and typically occur in the absence of
headache or visual changes;
occur after childbirth in about 25% of cases;
are tonic-clonic and resemble grand mal convulsions of
epilepsy;
may recur in rapid sequence, as in status epilepticus, and may
end in death;
will not be observed if the woman is alone;
may be followed by coma that lasts minutes or hours
depending on the frequency of convulsions.
Do not give ergometrine to women with pre-eclampsia,

eclampsia or high blood pressure because it increases the risk
of convulsions and cerebrovascular accidents.
MANAGEMENT OF PREGNANCY-INDUCED HYPERTENSION

BOX S-2 Prevention of pregnancy-induced hypertension
Restricting calories, fluids and salt intake does NOT prevent

pregnancy-induced hypertension and may even be harmful to the fetus.
The beneficial effects of aspirin, calcium and other agents in

preventing pregnancy-induced hypertension have not yet been proven.
Early detection and management in women with risk factors is
critical to the management of pregnancy-induced hypertension and the
prevention of convulsions. These women should be followed up
regularly and given clear instructions on when to return to their health
care provider. Education of immediate family members is equally
important, not only so that they understand the significance of signs of
pregnancy-induced hypertension progression but also to increase social
support when hospitalization and changes in work activities are
needed.
PREGNANCY-INDUCED HYPERTENSION
Manage on an outpatient basis:
Monitor blood pressure, urine (for proteinuria) and fetal condition
weekly.
If blood pressure worsens, manage as mild pre-eclampsia (page
S-42).
If there are signs of severe fetal growth restriction or fetal
compromise, admit the woman to the hospital for assessment and
possible expedited delivery.
Counsel the woman and her family about danger signals indicating
pre-eclampsia or eclampsia.
If all observations remain stable, allow to proceed with normal
labour and childbirth (page C-57).
MILD PRE-ECLAMPSIA
GESTATION LESS THAN 37 WEEKS

If signs remain unchanged or normalize, follow up twice a week as
an outpatient:
Monitor blood pressure, urine (for proteinuria), reflexes and fetal
condition.
Counsel the woman and her family about danger signals of severe
pre-eclampsia or eclampsia.
Encourage additional periods of rest.
• Encourage the woman to eat a normal diet (salt restriction should
be discouraged).
Do not give anticonvulsants, antihypertensives, sedatives or
tranquillizers.
• If follow-up as an outpatient is not possible, admit the woman to
the hospital:
Provide a normal diet (salt restriction should be discouraged);
Monitor blood pressure (twice daily) and urine for proteinuria
(daily);
Do not give anticonvulsants, antihypertensives, sedatives or
tranquillizers unless blood pressure or urinary protein level
increases;
Do not give diuretics. Diuretics are harmful and only indicated
for use in pre-eclampsia with pulmonary oedema or congestive
heart failure;
If the diastolic blood pressure decreases to normal levels or
her condition remains stable, send the woman home:
Advise her to rest and to watch out for significant
swelling or symptoms of severe pre-eclampsia;
See her twice weekly to monitor blood pressure, urine (for
proteinuria) and fetal condition and to assess for
symptoms and signs of severe pre-eclampsia;
If diastolic blood pressure rises again, readmit her;
If the signs remain unchanged, keep the woman in the

hospital. Continue the same management and monitor fetal
growth by symphysis-fundal height;
If there are signs of growth restriction, consider early
delivery. If not, continue hospitalization until term.
If urinary protein level increases, manage as severe pre-
eclampsia (see below).
Note: Symptoms and signs of pre-eclampsia do not completely
disappear until after pregnancy ends.
GESTATION MORE THAN 37 COMPLETE WEEKS

If there are signs of fetal compromise (e.g. decreased amniotic fluid,
growth restriction), assess the cervix (page P-18) and expedite
delivery:
If the cervix is favourable (soft, thin, partly dilated), rupture the
membranes with an amniotic hook or a Kocher clamp and induce
labour using oxytocin (page P-17).
If the cervix is unfavourable (firm, thick, closed), ripen the cervix
using prostaglandins or a Foley catheter (page P-24) or deliver by
SEVERE PRE-ECLAMPSIA AND ECLAMPSIA

Severe pre-eclampsia and eclampsia are managed similarly with the
exception that delivery must occur within 12 hours of onset of
convulsions in eclampsia. ALL cases of severe pre-eclampsia should
be managed actively. Symptoms and signs of "impending eclampsia"
(blurred vision, hyperreflexia) are unreliable and expectant
management is not recommended.
MANAGEMENT DURING A CONVULSION

Gather equipment (airway, suction, mask and bag, oxygen) and
give oxygen at 4-6 L per minute.
Protect the woman from injury but do not actively restrain her.
Prepare anticonvulsive drugs (page S-44).
GENERAL MANAGEMENT
After the convulsion:
Give anticonvulsive drugs (page P-44);
Position the woman on her left side to reduce risk of aspiration
of secretions, vomit and blood;
Aspirate the mouth and throat as necessary.
• Monitor vital signs (pulse, blood pressure, respiration), reflexes
and fetal heart rate hourly.
If diastolic blood pressure remains above 110 mm Hg, give
antihypertensive drugs (page S-46). Reduce the diastolic blood
pressure to less than 100 mm Hg but not below 90 mm Hg.
Catheterize the bladder to monitor urine output and proteinuria.
Maintain a strict fluid balance chart (monitor the amount of fluids
administered and urine output) to prevent fluid overload.
If urine output is less than 30 mL per hour:
Withhold magnesium sulfate and infuse IV fluids (normal
saline or Ringer's lactate) at 1 L in eight hours;
Monitor for the development of pulmonary oedema.
Never leave the woman alone. A convulsion followed by
aspiration of vomit may cause death of the woman and fetus.
• Auscultate the lung bases hourly for rales indicating pulmonary
oedema. If rales are heard, withhold fluids and give frusemide 40
mg IV once.
Assess clotting status with a bedside clotting test (page S-2).
ANTICONVULSIVE DRUGS
A key factor in anticonvulsive therapy is adequate administration of
anticonvulsive drugs. Convulsions in hospitalized women are most
frequently caused by under-treatment. Magnesium sulfate is the drug
of choice for preventing and treating convulsions in severe pre-
eclampsia and eclampsia. Administration is outlined in Box S-3 (page
S-45).
If magnesium sulfate is not available, diazepam may be used.

Although a single dose of diazepam seldom causes neonatal respiratory
depression, long-term continuous IV administration increases the risk
of respiratory depression in babies who may already be suffering from
the effects of utero-placental ischaemia and preterm birth. The effect
may last several days. Administration of diazepam is outlined in Box S-
4, page S-46.
BOXS-3 Magnesium sulfate schedules for severe pre-eclampsia
and eclampsia
Loading dose
Give 4 g of 20% magnesium sulfate solution IV over five minutes.
Follow promptly with 10 g of 50% magnesium sulfate solution: give 5 g in
each buttock as a deep IM injection with 1 mL of 2% lignocaine in the same
syringe. Ensure aseptic technique when giving magnesium sulfate deep IM
injection. Warn the woman that a feeling of warmth will be felt when
magnesium sulfate is given.
If convulsions recur after 15 minutes, give 2 g of 50% magnesium sulfate
solution IV over five minutes.
Maintenance dose
Give 5 g of 50% magnesium sulfate solution with 1 mL of 2% lignocaine in
the same syringe by deep IM injection into alternate buttocks every four
hours. Continue treatment for 24 hours after delivery or the last convulsion,
whichever occurs last.
If 50% solution is not available, give 1 g of20% magnesium sulfate solution
IV every hour by continuous infusion.
CLOSELY MONITOR THE WOMAN FOR SIGNS OF TOXICITY.
Before repeat administration, ensure that:

Respiratory rate is at least 16 per minute.
Patellar reflexes are present.
Urinary output is at least 30 mL per hour over four hours.
WITHHOW OR DELAY DRUG IF:
Respiratory rate falls below 16 per minute.
Patellar reflexes are absent.
Urinary output falls below 30 mL per hour over preceding four hours.
Keep antidote ready
In case of respiratory arrest:
Assist ventilation (mask and bag, anaesthesia apparatus, intubation).
Give calcium gluconate 1 g (10 mL of 10% solution) IV slowly until
calcium gluconate begins to antagonize the effects of magnesium sulfate
and respiration begins.
BOX S-4 Diazepam schedules for severe pre-eclampsia aud

eclampsia
Note: Use diazepam only if magnesium sulfate is not available.
Intravenous administration
Loading dose
Diazepam 10 mg IV slowly over two minutes.
If convulsions recur, repeat loading dose.
Maintenance dose
Diazepam 40 mg in 500 mL IV fluids (normal saline or Ringer's lactate)
titrated to keep the woman sedated but rousable.
Maternal respiratory depression may occur when dose exceeds 30 mg in one
hour:
Assist ventilation (mask and bag, anaesthesia apparatus, intubation), if
necessary.
Do not give more than 100 mg in 24 hours.
Rectal administration
Give diazepam rectally when IV access is not possible. The loading dose is
20 mg in a 10 mL syringe. Remove the needle, lubricate the barrel and insert
the syringe into the rectum to half its length. Discharge the contents and leave
the syringe in place, holding the buttocks together for 10 minutes to prevent
expulsion of the drug. Alternatively, the drug may be instilled in the rectum
through a catheter.
If convulsions are not controlled within 10 minutes, administer an
additional 10 mg or more, depending on the size of the woman and her
clinical response. Be prepared to assist ventilation.
ANTIHYPERTENSIVE DRUGS
If the diastolic blood pressure is 110 mm Hg or more, give
antihypertensive drugs. The goal is to keep the diastolic pressure
between 90 mm Hg and 100 mm Hg to prevent cerebral haemorrhage.
Hydralazine is the drug of choice.
Give hydralazine 5 mg IV slowly every five minutes until blood
pressure is lowered. Repeat hourly as needed or give hydralazine
12.5 mg IM every two hours as needed.
If hydralazine is not available, give labetolol or nifedipine:
labetolol 10 mg IV:
If response to labetolol is inadequate (diastolic blood
pressure remains above 110 mm Hg) after 10 minutes,
give labetolol 20 mg IV;
Headache, blurred vision, convulsions or loss of consciousness, elevated blood pressure 5-47
Increase the dose to 40 mg and then 80 mg if satisfactory

response is not obtained after 10 minutes of each dose;
nifedipine 5 mg under the tongue:
If response to nifedipine is inadequate (diastolic blood
pressure remains above 110 mm Hg) after 10 minutes,
give an additional 5 mg under the tongue.
Note: There is concern regarding a possibility for an interaction
with magnesium sulfate that can lead to hypotension.
DELIVERY
Delivery should take place as soon as the woman's condition has
stabilized. Delaying delivery to increase fetal maturity will risk the
lives of both the woman and the fetus. Delivery should occur regardless
of the gestational age.
In severe pre-eclampsia, delivery should occur within 24

hours of the onset of symptoms. In eclampsia, delivery should
occur within 12 hours of the onset of convulsions.
• Assess the cervix (page P-18).

• If the cervix is favourable (soft, thin, partly dilated), rupture the
membranes with an amniotic hook or a Kocher clamp and induce
If vaginal delivery is not anticipated within 12 hours (for
eclampsia) or 24 hours (for severe pre-eclampsia), deliver by
• If there are fetal heart rate abnormalities (less than 100 or more
than 180 beats per minute), deliver by caesarean section (page
P-43).
If the cervix is unfavourable (firm, thick, closed) and the fetus is
alive, deliver by caesarean section (page P-43).
If safe anaesthesia is not available for caesarean section or if the
fetus is dead or too premature for survival:
Aim for vaginal delivery;
If the cervix is unfavourable (firm, thick, closed), ripen the
cervix using misoprostol, prostaglandins or a Foley catheter
(page P-24).
Note: If caesarean section is performed, ensure that:

Coagulopathy has been ruled out;
Safe general anaesthesia is available. Spinal anaesthesia is
associated with the risk of hypotension. This risk can be reduced if
adequate IV fluids (500-1000 mL) are infused prior to
administration of the anaesthetic (page P-11).
Do not use local anaesthesia or ketamine in women with pre-

eclampsia or eclampsia.
POSTPARTUM CARE
Anticonvulsive therapy should be maintained for 24 hours after
delivery or the last convulsion, whichever occurs last.
Continue antihypertensive therapy as long as the diastolic pressure
is 110 mm Hg or more.
Continue to monitor urine output.
REFERRAL FOR TERTIARY LEVEL CARE

Consider referral of women who have:
oliguria that persists for 48 hours after delivery;
coagulation failure (e.g. coagulopathy [page S-19] or haemolysis,
elevated liver enzymes and low platelets [HELLP] syndrome);
persistent coma lasting more than 24 hours after convulsion.
COMPLICATIONS OF PREGNANCY-INDUCED HYPERTENSION

Complications may cause adverse perinatal and maternal outcomes.
Because complications are often difficult to treat, efforts should be
made to prevent them by early diagnosis and proper management.
Health care providers should be aware that management can also lead
to complications. Manage complications as follows:
If fetal growth restriction is severe, expedite delivery.
If there is increasing drowsiness or coma, suspect cerebral
haemorrhage:
Reduce blood pressure slowly to reduce the risk of cerebral
haemorrhage;
Provide supportive therapy and prepare to refer the woman for

tertiary level care.
• If heart, kidney or liver failure is suspected, provide supportive
therapy and prepare to refer the woman for tertiary level care.
If a clotting test shows failure of a clot to form after seven
minutes or a soft clot that breaks down easily, suspect
If the woman has IV lines and catheters, she is prone to
infection. Use proper infection prevention techniques (page C-17)
and closely monitor for signs of infection.
If the woman is receiving IV fluids, she is at risk of circulatory
overload. Maintain a strict fluid balance chart and monitor the
amount of fluids administered and urine output.
CHRONIC HYPERTENSION
Encourage additional periods of rest.
High levels of blood pressure maintain renal and placental
perfusion in chronic hypertension; reducing blood pressure will
result in diminished perfusion. Blood pressure should not be
lowered below its pre-pregnancy level. There is no evidence that
aggressive treatment to lower the blood pressure to normal levels
improves either fetal or maternal outcome:
If the woman was on anti-hypertensive medication before
pregnancy and the disease is well-controlled, continue the
same medication if acceptable in pregnancy;
If diastolic blood pressure is 110 mm Hg or more, or
systolic blood pressure is 160 mm Hg or more, treat with
antihypertensive drugs (page S-46);
If proteinuria or other signs and symptoms are present,
consider superimposed pre-eclampsia and manage as mild pre-
eclampsia (page S-42).
Monitor fetal growth and condition.
If there are no complications, deliver at term.
• If pre-eclampsia develops, manage as mild pre-eclampsia (page
S-42) or severe pre-eclampsia (page S-43).
If there are fetal heart rate abnormalities (less than 100 or more
If fetal growth restriction is severe and pregnancy dating is
accurate, assess the cervix (page P-18) and consider delivery:
Note: Assessment of gestation by ultrasound in late pregnancy is
not accurate.
If the cervix is favourable (soft, thin, partly dilated), rupture
the membranes with an amniotic hook or a Kocher clamp and
induce labour using oxytocin (page P-17);
cervix using prostaglandins or a Foley catheter (page P-24).
Observe for complications including abruptio placentae (page
S-18) and superimposed pre-eclampsia (see Mild pre-eclampsia,
page S-42).
TETANUS
Clostridium tetani may enter the uterine cavity on unclean instruments
or hands, particularly during non-professional abortions or non-
institutional deliveries. The newborn is usually infected from unclean
instruments used in cutting the cord or from contaminated substances
applied as traditional cord dressings. Begin treatment as soon as
possible.
Control spasms with diazepam 10 mg IV slowly over two minutes.
If spasms are severe, the woman may have to be paralyzed and
put on a ventilator. This may be possible only at a tertiary care
centre.
Provide general care:
Nurse in a quiet room but monitor closely;
Avoid unnecessary stimuli;
Maintain hydration and nutrition;
Treat secondary infection.
Give tetanus antitoxin 3000 units IM to neutralize absorbed toxin.
Prevent further production of toxin:
Remove the cause of sepsis (e.g. remove infected tissue from
uterine cavity in a septic abortion);
Headache, blurred vision, convulsions or loss of consciousness, elevated blood pressure S·51
Give benzyl penicillin 2 million units IV every four hours for

48 hours, then give ampicillin 500 mg by mouth three times
per day for 10 days.
BOX S-S Tetanus immunization
When the mother has active immunity, the antibodies pass through the
placenta, protecting the newborn. A woman is considered protected when
she has received two vaccine doses at least four weeks apart, with an
interval of at least four weeks between the last vaccine dose and pregnancy
termination. Women who last received a vaccination series (five injections)
more than 10 years before the present pregnancy should be given a booster.
In most women a booster is recommended in every pregnancy.
If an immunized woman has had an unsafe abortion or unhygienic

delivery, give her a booster injection of tetanus toxoid 0.5 mL IM. If she
has not been immunized before, give her anti-tetanus serum 1500 units
IM and a booster injection of tetanus toxoid 0.5 mL IM after four weeks.
EPILEPSY
Women with epilepsy can present with convulsions in pregnancy. Like
many chronic diseases, epilepsy worsens in some women during
pregnancy but improves in others. In the majority of women, however,
epilepsy is unaffected by pregnancy.
Observe the woman closely. In general, pregnant women with
epilepsy have an increased risk of:
pregnancy-induced hypertension;
preterm labour;
infants with low birth weights;
infants with congenital malformations;
perinatal mortality.
Aim to control epilepsy with the smallest dose of a single drug.
Avoid drugs in early pregnancy which are associated with
congenital malformations (e.g. valproic acid).
• If the woman is convulsing, give diazepam 10 mg IV slowly over
two minutes. Repeat if convulsions recur after 10 minutes.
If convulsions continue (status epilepticus), infuse phenytoin 1 g

(approximately 18 mg/kg body weight) in 50-100 mL normal
saline over 30 minutes (final concentration not to exceed 10 mg per
mL):
Note: Only normal saline can be used to infuse phenytoin. All
other IV fluids will cause crystallization of phenytoin.
Flush IV line with normal saline before and after infusing
phenytoin;
Do not infuse phenytoin at a rate exceeding 50 mg per minute
due to the risk of irregular heart beat, hypotension and
respiratory depression;
Complete administration within one hour of preparation.
If the woman is known to be epileptic, give her the same
medication that she had been taking. Follow-up with her regularly
and adjust the dose of medication according to the response.
If the woman is known to be epileptic but cannot recall details
of her medication, give her phenytoin 100 mg by mouth three
times per day. Follow-up with her regularly and adjust the dose of
medication according to her response.
Folic acid deficiency may be caused by anticonvulsive drugs. Give
folic acid 600 mcg by mouth once daily along with antiepileptic
treatment in pregnancy.
Phenytoin can cause neonatal deficiency of vitamin K-dependent
clotting factors. This can be minimized by giving vitamin K 1 mg
IM to the newborn.
Evaluation for underlying causes of convulsions is indicated if
convulsions are of recent onset. This may be possible only at the
tertiary care level.
SEVERE/COMPLICATED MALARIA
Severe malaria in pregnancy may be misdiagnosed as eclampsia. If a
pregnant woman living in a malarial area has fever, headaches or
convulsions and malaria cannot be excluded, it is essential to treat
the woman for both malaria and eclampsia.
Pregnant women with severe malaria are particularly prone

to hypoglycaemia, pulmonary oedema, anaemia and coma.
ANTIMALARIAL DRUGS
Quinine remains the first line treatment in many countries and may be
safely used throughout pregnancy. Where available, artesunate IV or
artemether IM are the drugs of choice in the second and third
trimesters. Their use in the first trimester must balance their advantages
over quinine (better tolerability, less hypoglycaemia) against the limited
documentation of pregnancy outcomes.
QUININE DIHYDROCHLORIDE
LOADING DOSE
• Infuse quinine dihydrochloride 20 mg/kg body weight in IV fluids
(5% dextrose, normal saline or Ringer's lactate) over four hours:
Never give an IV bolus injection of quinine;
If it is definitely known that the woman has taken an
adequate dose of quinine ( 1.2 g) within the preceding 12
hours, do not give the loading dose. Proceed with the
maintenance dose (see below);
If the history of treatment is not known or is unclear, give
the loading dose of quinine;
Use 100-500 mL IV fluids depending on the fluid balance
state.
Wait four hours before giving the maintenance dose.
MAINTENANCE DOSE
Infuse quinine dihydrochloride 10 mg/kg body weight over four
hours. Repeat every eight hours (i.e. quinine infusion for four
hours, no quinine for four hours, quinine infusion for four hours,
etc.).
Note: Monitor blood glucose levels for hypoglycaemia every hour
while the woman is receiving quinine IV (pageS-55).
Continue the maintenance dosing schedule until the woman is
conscious and able to swallow and then give:
quinine dihydrochloride or quinine sulfate 10 mg/kg body
weight by mouth every eight hours to complete seven days of
treatment;
OR in areas where sulfadoxine/pyrimethamine is effective,
give sulfadoxine/pyrimethamine three tablets as a single dose.
S·54 Elevated blood pressure, headache, blurred vision, convulsions or loss of consciousness
INTRAVENOUS ARTESUNATE
LOADING DOSE
Give artesunate 2.4 mg/kg body weight IV as a single bolus on the
first day of treatment.
MAINTENANCE DOSE
Give artesunate 1.2 mg/kg body weight IV as a single bolus once
daily beginning on the second day of treatment.
• Continue the maintenance dosing schedule until the woman is
conscious and able to swallow and then give artesunate 2 mg/kg
body weight by mouth once daily to complete seven days of
treatment.
INTRAMUSCULAR ARTEMETHER
LOADING DOSE
Give artemether 3.2 mg/kg body weight IM as a single dose on the
first day of treatment.
MAINTENANCE DOSE
Give artemether 1.6 mg/kg body weight IM once daily beginning
on the second day of treatment.
Continue the maintenance dosing schedule until the woman is
conscious and able to swallow and then give artesunate 2 mg/kg
body weight by mouth once daily to complete seven days of
treatment.
CONVULSIONS
If convulsions occur, give diazepam 10 mg IV slowly over two
minutes.
If eclampsia is diagnosed in addition to malaria, prevent
subsequent convulsions with magnesium sulfate (Box S-3, page
S-45).
If eclampsia is excluded, prevent subsequent convulsions with

phenytoin (below).
PHENYTOIN
LOADING DOSE
Infuse phenytoin 1 g (approximately 18 mg/kg body weight) in
50-100 mL normal saline over 30 minutes (final concentration not
to exceed 10 mg per mL):
Note: Only normal saline can be used to infuse phenytoin. All

other IV fluids will cause crystallization of phenytoin.
Flush IV line with normal saline before and after infusing
phenytoin;
Do not infuse phenytoin at a rate exceeding 50 mg per minute
due to the risk of irregular heart beat, hypotension and
respiratory depression;
Complete administration within one hour of preparation.
MAINTENANCE DOSE
Give phenytoin 100 mg IV slowly over two minutes or by mouth
every eight hours beginning at least 12 hours after the loading
dose.
FLUID BALANCE
Maintain a strict fluid balance chart and monitor the amount of
fluids administered and urine output to ensure that there is no fluid
overload. Assess clinical status regularly.
Note: Women with severe malaria are prone to fluid overload.
If pulmonary oedema develops:
Prop up the woman;
Give oxygen at 4 L per minute by mask or nasal cannulae;
Give frusemide 40 mg IV as a single dose.
If urine output is poor (less than 30 mL per hour):
Measure serum creatinine;
Rehydrate with IV fluids (normal saline, Ringer's lactate).
If urine output does not improve, give frusemide 40 mg IV as a
single dose and continue to monitor urine output.
If urine output is still poor (less than 30 mL per hour over four
hours) and the serum creatinine is more than 2.9 mgldL, refer
the woman to a tertiary care centre, if possible, for management of
renal failure.
HYPOGLYCAEMIA
Hypoglycaemia is common and occurs at any time during the illness,
especially after initiation of quinine therapy. There may be no
symptoms.
Monitor blood glucose levels using a stix test every four hours.
Note: If the woman is receiving quinine IV, monitor blood
glucose levels every hour.
If hypoglycaemia is detected, give 50% dextrose 50 mL IV
followed by dextrose (5 or 10%) 500 mL infused over eight hours.
Note: Monitor blood glucose levels and adjust infusion
accordingly.
Monitor fluid balance carefully (page S-55).
ANAEMIA
Complicated malaria is often accompanied by anaemia.
Monitor haemoglobin levels daily.
Transfuse as necessary (page C-23).
Monitor fluid balance (pageS-55).
Give frusemide 20 mg IV or by mouth with each unit of blood.
Give ferrous sulfate or ferrous fumerate 60 mg by mouth PLUS
folic acid 400 mcg by mouth once daily upon discharge.
UNSATISFACTORY PROGRESS OF LABOUR S-57
PROBLEMS
Cervix not dilated beyond 4 cm after 8 hours of regular contractions.
Cervical dilatation is to the right of the alert line on the partograph.
The woman has been experiencing labour pains for 12 hours or more
without delivery (prolonged labour).
GENERAL MANAGEMENT
Perform a rapid evaluation of the condition of the woman and fetus
and provide supportive care (page C-57).
Test urine for ketones and treat with IV fluids if ketotic.
• Review partograph (page C-65).
DIAGNOSIS
TABLES-10 Diagnosis of unsatisfactory progress of labour
Findings Diagnosis
Cervix not dilated. No palpable contractions or False labour, page S-64
infrequent contractions
Cervix not dilated beyond 4 cm after eight hours of Prolonged latent phase,
regular contractions page S-64
Cervical dilatation to the right of the alert line on the Prolonged active phase,
partograph (Fig S-6, page S-59) page S-65
• Secondary arrest of cervical dilatation and descent • Cephalopelvic
of presenting part in presence of good contractions disproportion, page S-
65
• Secondary arrest of cervical dilatation and descent • Obstruction, page S-66
of presenting part with large caput, third degree
moulding, cervix poorly applied to presenting part,
oedematous cervix, ballooning of lower uterine
segment, formation of retraction band or maternal
and fetal distress (Fig S-7, page S-61)
• Two contractions or less in I 0 minutes, each • Inadequate uterine
lasting less than 40 seconds (Fig S-8, page S-63) activity, page S-66
• Presentation other than vertex with occiput • Malpresentation or
anterior malposition, page S-69
Cervix fully dilated and woman has urge to push, but Prolonged expulsive
no descent phase, page S-67
S-58 Unsatisfactory progress of labour
Figure S-6, page S-59 is a sample partograph for prolonged active

phase of labour. Note that the partograph was not adequately filled
out and that this example demonstrates inappropriate management
of prolonged labour. The diagnosis of prolonged labour was evident at
2 PM and labour should have been augmented with oxytocin at that
time.
The woman was admitted in active labour at 10 AM:
inadequate uterine contractions (two in 10 minutes, each
lasting less than 20 seconds).
At2PM:
fetal head still 5/5 palpable;
cervix dilated 4 cm and to the right of the alert line;
membranes have ruptured spontaneously and amniotic fluid is
clear;
inadequate uterine contractions (one in 10 minutes, lasting less
than 20 seconds).
At6PM:
contractions still inadequate (two in 10 minutes, each lasting
less than 20 seconds).
At9PM:
fetal heart rate 80 per minute;
amniotic fluid stained with meconium;
no further progress in labour.
Caesarean section performed at 9:20PM due to fetal distress.
FIGURE S-6 Partograph showing prolonged active phase of labour

Name Mrs. M Gravida 1 Para 0+0 Hosprtal number 1248
Hf
10
1/v ~
L_,;'
1---- 21:20
I ~~ I L" velf~ tm•l e
~e~"' ~c;,
I ~oJ/ in a t
Cervix (cm)
[Plot X]
-- -I-
... v
J3' '/'
...... ~ -f.-"
I~ t. 2 6i0 9
I/;' l..ol~- r--.

Descent
. . . . i'
ofheac:l 3
-[Plr:
Hours 1 2 3 4 5 6 7 8 9 10 11 12
Time 10 11 12 13 14 15 16 17 18 19 20 21
""=~~B±ll± W IIIIIIIIIIIIIIII
Drugs given
and IV fluids
Figure S-7, page S-61 is a sample partograph showing arrest of

dilatation and descent in the active phase of labour. Fetal distress and
third degree moulding, together with arrest of dilatation and descent in
the active phase of labour in the presence of adequate uterine
contractions, indicates obstructed labour.
three contractions in 10 minutes, each lasting 20-40 seconds;
clear amniotic fluid draining;
first degree moulding.
At2PM:
cervix dilated 6 cm and to the right of the alert line;
slight improvement in contractions (three in 10 minutes, each
lasting 45 seconds);
second degree moulding.
At5 PM:
cervix still dilated 6 cm;
third degree moulding;
fetal heart rate 92 per minute;
amniotic fluid stained with meconium.
Caesarean section performed at 5:30PM due to fetal distress.
FIGURE S-7 Partograph showing obstructed labour

Name Mrs. H Gravida ~ Para 3•0 Hospital number 6639
Date of admission 20.5.2000 Time of admission 10:00 A. M. Ruptured membranes 1 hours
..,.....-"'~ /
I ..,.....,.. I I ..,.....,..
~e~/ l&oJ~"'
cr.,... ~~
1// !--" ...... 1.....-""
..,e:::::::~
....... "" lo~ i t 1 :.!!b
L"'
Wt
• n al ~
~.6 03g
i~f n
Hours 1 2 3 4 5 6 7 8 9 10 11 12
Time 10 11 12 13 14 15 16 17
/!,'lr/1,~~~/,~•
~~~00~~ 11 I 11
Oxytocin UIL
drops/m in I I I IIIIIIIII I I I I I I IIIIIII
Drugs given
and IV fluids
180
170
180
Pulse •150
140
andT 130
BPl ~~ 100
90
80 y
70
eo ""'
Temp'CI36.81 1371 1371 I
1~1111~1111111
prcteinl
Urine acetone
{
volume
S·62 Unsatisfactory progress of labour
Figure S-8, page S-63 is a sample partograph for poor progress of

labour due to inadequate uterine contractions corrected with oxytocin.
two contractions in 10 minutes, each lasting less than 20
seconds.
• At 12PM:
cervix still dilated 4 cm and to the right of the alert line;
no improvement in contractions.
At2PM:
poor progress of labour due to inefficient uterine contractions
diagnosed;
augmented labour with oxytocin 10 units in 1 L IV fluids at 15
drops per minute;
escalated oxytocin until a good pattern of contractions was
established.
At7 PM:
four contractions in I 0 minutes, each lasting 45 seconds.
Spontaneous vaginal delivery occurred at 8:10PM.
FIGURES-8 Partograph showing inadequate uterine

contractions corrected with oxytocin
Name Mrs. :r Gravida 1 Para 0+0 Hospital number 1443
Date of admission 2.5.2000 Time of admission 10:00 A.M. Ruptured membranes 13:30 hours
200
190
180
170
160
Fetal 150
heart140
rate 130
120
110
100
T.
Moulding
,.,._,,
I [/ ....... "' ly ., .......
~0~ ...... I ~t?
Cervix (an) )} "P" S~D Q 20:10
[lPidXT : ....... -1:::;:; ~ Uite 111 1le irfant

1/ ~r--- / ....... l~t. 2 6~ i4~
Descent r-,
[10]:
ofhead 3
1'1'-..
....... ,
1"'...._
Hours 1 2 3 4 5 6 7 8 9 10 11 12
lime 10 11 12 13 14 1!i 16 17 18 19 20
Drugs given
and IV fluids
160
170
160
Pulse • 150
·=r;1111!111!!11111111!iili!-lllll
. 60~~~~~~==~~~~~~~
Temp ·c 136.21 136.21 136.81 I 37 I I 37 I I
,-<:::1~1 I I I I I 1:1 I I I I
MANAGEMENT
FALSE LABOUR
Examine for urinary tract or other infection (Table S-13, page S-100)
or ruptured membranes (page S-135) and treat accordingly. If none of
these are present, discharge the woman and encourage her to return if
signs oflabour recur.
PROLONGED LATENT PHASE

The diagnosis of prolonged latent phase is made retrospectively. When
contractions cease, the woman is said to have had false labour. When
contractions become regular and dilatation progresses beyond 4 cm, the
woman is said to have been in the latent phase.
Misdiagnosing false labour or prolonged latent phase leads to

unnecessary induction or augmentation, which may fail. This
may lead to unnecessary caesarean section and amnionitis.
If a woman has been in the latent phase for more than eight hours
and there is little sign of progress, reassess the situation by assessing
the cervix:
If there has been no change in cervical effacement or dilatation
and there is no fetal distress, review the diagnosis. The woman may
not be in labour.
• If there has been a change in cervical effacement or dilatation,
rupture the membranes with an amniotic hook or a Kocher clamp
and induce labour using oxytocin (page P-17):
Reassess every four hours;
If the woman has not entered the active phase after eight
hours of oxytocin infusion, deliver by caesarean section
(page P-43).
discharge):
Augment labour immediately with oxytocin (page P-25);
Give a combination of antibiotics until delivery (page C-35):

hours;
If the woman delivers vaginally, discontinue antibiotics
postpartum;
If the woman has a caesarean section, continue
antibiotics PLUS give metronidazole 500 mg IV every
eight hours until the woman is fever-free for 48 hours.
PROLONGED ACTIVE PHASE

If there are no signs of cephalopelvic disproportion or obstruction
and the membranes are intact, rupture the membranes with an
amniotic hook or a Kocher clamp (page P-17).
Assess uterine contractions:
If contractions are inefficient (less than three contractions in
10 minutes, each lasting less than 40 seconds), suspect
inadequate uterine activity (page S-66);
If contractions are efficient (three or more contractions in 10
minutes, each lasting more than 40 seconds) suspect
cephalopelvic disproportion, obstruction, malposition or
malpresentation (see below).
General methods of labour support may improve contractions and
accelerate progress (page C-57).
CEPHALOPELVIC DISPROPORTION
Cephalopelvic disproportion occurs because the fetus is too large or the
maternal pelvis is too small. If labour persists with cephalopelvic
disproportion, it may become arrested or obstructed. The best test to
determine if a pelvis is adequate is a trial of labour. Clinical pelvimetry
is of limited value.
If cephalopelvic disproportion is confirmed (Table S-10, page
S-57), deliver by caesarean section (page P-43):
If the fetus is dead:
Deliver by craniotomy (page P-57);
If the operator is not proficient in craniotomy, deliver
by caesarean section (page P-43).
OBSTRUCTION
Note: Rupture of an unscarred uterus is usually caused by obstructed
labour.
• If the fetus is alive, the cervix is fully dilated and the fetal head is
at 0 station or below, deliver by vacuum extraction (page P-27).
If there is an indication for vacuum extraction and
symphysiotomy for relative obstruction and the fetal head is at -2
station:
Deliver by vacuum extraction (page P-27) and
symphysiotomy (page P-53);
If the operator is not proficient in symphysiotomy, deliver
• If the fetus is alive but the cervix is not fully dilated or if the fetal
head is too high for vacuum extraction, deliver by caesarean
If the fetus is dead:
If the operator is not proficient in craniotomy, deliver by
INADEQUATE UTERINE ACTIVITY

If contractions are inefficient and cephalopelvic disproportion and
obstruction have been excluded, the most probable cause of
prolonged labour is inadequate uterine activity.
Inefficient contractions are less common in a multigravida

than in a primigravida. Hence, every effort should be made to
rule out disproportion in a multigravida before augmenting
with oxytocin.
Rupture the membranes with an amniotic hook or a Kocher clamp

and augment labour using oxytocin (page P-17).
Reassess progress by vaginal examination two hours after a good
contraction pattern with strong contractions has been established:
If there is no progress between examinations, deliver by
caesarean section (page P-43);
If progress continues, continue oxytocin infusion and re-

examine after two hours. Continue to follow progress
carefully.
PROLONGED EXPULSIVE PHASE

Maternal expulsive efforts increase fetal risk by reducing the delivery
of oxygen to the placenta. Allow spontaneous maternal "pushing," but
do not encourage prolonged effort and holding the breath.
If malpresentation and obvious obstruction have been excluded,
augment labour with oxytocin (page P-25).
If there is no descent after augmentation:
If the fetal head is not more than 1/5 above the symphysis
pubis or the leading bony edge of the fetal head is at 0
station, deliver by vacuum extraction (page P-27) or forceps
(page P-33);
If the fetal head is between 1/5 and 3/5 above the symphysis
pubis or the leading bony edge of the fetal head is between 0
station and -2 station:
If the operator is not proficient in symphysiotomy,
deliver by caesarean section (page P-43).
If the fetal head is more than 3/5 above the symphysis pubis
or the leading bony edge of the fetal head is above -2 station,
deliver by caesarean section (page P-43).
MALPOSITIONS AND MALPRESENTATIONS S-69
Mal positions are abnormal positions of the vertex of the fetal head
(with the occiput as the reference point) relative to the maternal pelvis.
Mal presentations are all presentations of the fetus other than vertex.
PROBLEM
The fetus is in an abnormal position or presentation that may result
in prolonged or obstructed labour.
GENERAL MANAGEMENT
temperature).
Assess fetal condition:
Listen to the fetal heart rate immediately after a contraction:
Count the fetal heart rate for a full minute at least once
every 30 minutes during the active phase and every five
minutes during the second stage;
If there are fetal heart rate abnormalities (less than 100
or more than 180 beats per minute), suspect fetal distress
(page S-95).
If the membranes have ruptured, note the colour of the
draining amniotic fluid:
Presence of thick meconium indicates the need for close
monitoring and possible intervention for management of
fetal distress (page S-95);
Absence of fluid draining after rupture of the membranes
is an indication of reduced volume of amniotic fluid,
which may be associated with fetal distress.
• Provide encouragement and supportive care (page C-57).
Review progress of labour using a partograph (page C-65).
Note: Observe the woman closely. Malpresentations increase the risk
for uterine rupture because of the potential for obstructed labour.
S-70 Malpositions and malpresentations
DIAGNOSIS
DETERMINE THE PRESENTING PART

The most common presentation is the vertex of the fetal head. If
the vertex is not the presenting part, see Table S-12, page S-73.
If the vertex is the presenting part, use landmarks of the fetal
skull to determine the position of the fetal head (Fig S-9).
FIGURES-9 Landmarks of the fetal skull
DETERMINE THE POSITION OF THE FETAL HEAD

The fetal head normally engages in the maternal pelvis in an
occiput transverse position, with the fetal occiput transverse in the
maternal pelvis (Fig S-10).
FIGURES-10 Occiput transverse positions
Left occiput transverse Right occiput transverse
• With descent, the fetal head rotates so that the fetal occiput is
anterior in the maternal pelvis (Fig S-11). Failure of an occiput
transverse position to rotate to an occiput anterior position should
be managed as an occiput posterior position (page S-75).
FIGURE S-11 Occiput anterior positions
Left occiput anterior Right occiput anterior
Occiput anterior
An additional feature of a normal presentation is a well-flexed

vertex (Fig S-12), with the fetal occiput lower in the vagina than
the sinciput.
FIGURES-12 Well-flexed vertex
Sinciput
Occiput
If the fetal head is well-flexed with occiput anterior or occiput

transverse (in early labour), proceed with delivery (page C-71).
If the fetal head is not occiput anterior, identify and manage the
malposition (Table S-11, page S-72).
• If the fetal head is not the presenting part or the fetal head is
not well-flexed, identify and manage the malpresentation (Table
S-12, page S-73).
TABLES-11 Diagnosis of mal positions
Symptoms and Signs Figure
OCCIPUT POSTERIOR FIGURES-13

POSITION occurs when the fetal
occiput is posterior in relation to the
maternal pelvis (Fig S-13 and Fig
S-14).
On abdominal examination, the

lower part of the abdomen is flattened,
fetal limbs are palpable anteriorly and
the fetal heart may be heard in the
Occiput posterior
flank.
On vaginal examination, the

FIGURES-14
posterior fontanelle is towards the
sacrum and the anterior fontanelle
may be easily felt if the head is
deflexed.
For management, see page S-75.
Left occiput posterior
OCCIPUT TRANSVERSE FIGURES-15

POSITION occurs when the fetal
occiput is transverse to the maternal
pelvis (Fig S-15). If an occiput
transverse position persists into the
later part of the first stage of labour, it
should be managed as an occiput
posterior position (page S-75).
Left occiput transverse

TABLES-12 Diagnosis of malpresentations
BROW PRESENTATION is caused FIGURES-16

by partial extension of the fetal head
so that the occiput is higher than the
sinciput (Fig S-16).
On abdominal examination, more

than half the fetal head is above the
symphysis pubis and the occiput is
palpable at a higher level than the
sinciput.
On vaginal examination, the anterior

fontanelle and the orbits are felt.
FACE PRESENTATION is caused FIGURES-17

by hyper-extension of the fetal head so
that neither the occiput nor the
sinciput are palpable on vaginal
examination (Fig S-17 and Fig S-18).
On abdominal examination, a groove

may be felt between the occiput and
the back.
On vaginal examination, the face is

palpated, the examiner's finger enters
the mouth easily and the bony jaws are
felt. FIGURES-IS

TABLE S-12 Cont. Diagnosis of malpresentations
COMPOUND PRESENTATION FIGURE S-19

occurs when an arm prolapses
alongside the presenting part. Both the
prolapsed arm and the fetal head
present in the pelvis simultaneously
(Fig S-19).
BREECH PRESENTATION occurs FIGURE S-20

when the buttocks and/or the feet are
the presenting parts.
On abdominal examination, the head

is felt in the upper abdomen and the
breech in the pelvic brim.
Auscultation locates the fetal heart
higher than expected with a vertex
presentation.
FIGURE S-21
On vaginal examination during
labour, the buttocks and/or feet are
felt; thick, dark meconium is normal.
COMPLETE(FLEXED)BREECH
PRESENTATION occurs when both
legs are flexed at the hips and knees
(Fig S-20).
FIGURES-22
FRANK(EXTENDED)BREECH
PRESENTATION occurs when both
legs are flexed at the hips and
extended at the knees (Fig S-21).
FOOTLING BREECH
PRESENTATION occurs when a leg
is extended at the hip and the knee
(Fig S-22).
TABLE S-12 Cont. Diagnosis ofmalpresentations
TRANSVERSE LIE AND FIGURES-23

SHOULDER PRESENTATION
occur when the long axis of the fetus
is transverse (Fig S-23). The shoulder
is typically the presenting part.
On abdominal examination, neither

the head nor the buttocks can be felt at
(r., . -,c ... .,...~
the symphysis pubis and the head is
usually felt in the flank.
ffi - '
~---
,.;,' ~ ....S··- ... _
' ...... ____ , , ...

On vaginal examination, a shoulder
may be felt, but not always. An arm
may prolapse and the elbow, arm or
hand may be felt in the vagina.
y
For management, see page S·81.
MANAGEMENT
OCCIPUT POSTERIOR POSITIONS

Spontaneous rotation to the anterior position occurs in 90% of cases.
Arrested labour may occur when the head does not rotate and/or
descend. Delivery may be complicated by perineal tears or extension of
an episiotomy.
• If there are signs of obstruction but the fetal heart rate is
normal, allow the woman to walk around or change position to
encourage spontaneous rotation.
If there are signs of obstruction and the fetal heart rate is
abnormal (less than 100 or more than 180 beats per minute) at any
stage, deliver by caesarean section (page P-43).
• If the membranes are intact, rupture the membranes with an
amniotic hook or a Kocher clamp (page P-17).
If the cervix is not fully dilated and there are no signs of
obstruction, augment labour with oxytocin (page P-25).
If the cervix is fully dilated but there is no descent in the

expulsive phase, assess for signs of obstruction (Table S-10, page
S-57):
If there are no signs of obstruction, augment labour with
oxytocin (page P-25).
If the cervix is fully dilated and if:
the fetal head is more than 3/5 above the symphysis pubis or
the leading bony edge of the fetal head is above -2 station,
perform caesarean section (page P-43);
the fetal head is between 1/5 and 3/5 above the symphysis
pubis or the leading bony edge of the fetal head is between 0
station and -2 station:
If the operator is not proficient in symphysiotomy,
perform caesarean section (page P-43);
the fetal head is not more than 115 above the symphysis
pubis or the leading bony edge of the fetal head is at 0
station, deliver by vacuum extraction (page P-27) or forceps
(page P-33).
BROW PRESENTATION
In brow presentation, engagement is usually impossible and arrested
labour is common. Spontaneous conversion to either vertex
presentation or face presentation can rarely occur, particularly when the
fetus is small or when there is fetal death with maceration. It is unusual
for spontaneous conversion to occur with an average-sized live fetus
once the membranes have ruptured.
If the fetus is alive, deliver by caesarean section (page P-43).
If the fetus is dead and:
the cervix is not fully dilated, deliver by caesarcan section
(page P-43);
the cervix is fully dilated:
If the operator is not proficient in craniotomy, deliver

Do not deliver brow presentation by vacuum extraction, outlet

forceps or symphysiotomy.
FACE PRESENTATION
The chin serves as the reference point in describing the position of the
head. It is necessary to distinguish only chin-anterior positions, in
which the chin is anterior in relation to the maternal pelvis (Fig S-24
A), from chin-posterior positions (Fig S-24 B).
FIGURE S-24 Face presentation
A. Chin anterior B. Chin posterior
Prolonged labour is common. Descent and delivery of the head by

flexion may occur in the chin-anterior position. In the chin-posterior
position, however, the fully extended head is blocked by the sacrum.
This prevents descent and labour is arrested.
CHIN-ANTERIOR POSITION
If the cervix is fully dilated:
Allow to proceed with normal childbirth (page C-71);
If there is slow progress and no sign of obstruction (Table
S-10, page S-57), augment labour with oxytocin (page P-25);
If descent is unsatisfactory, deliver by forceps (page P-33).

If the cervix is not fully dilated and there are no signs of
obstruction, augment labour using oxytocin (page P-25). Review
progress as with vertex presentation.
CHIN-POSTERIOR POSITION
If the cervix is fully dilated, deliver by caesarean section
(page P-43).
If the cervix is not fully dilated, monitor descent, rotation and
progress. If there are signs of obstruction, deliver by caesarean
• If the fetus is dead:
If the operator is not proficient in craniotomy, deliver by
Do not perform vacuum extraction for face presentation.
COMPOUND PRESENTATION
Spontaneous delivery can occur only when the fetus is very small or
dead and macerated. Arrested labour occurs in the expulsive stage.
Replacement of the prolapsed arm is sometimes possible:
Assist the woman to assume the knee-chest position
(Fig S-25);
Push the arm above the pelvic brim and hold it there until a
contraction pushes the head into the pelvis.
Proceed with management for normal childbirth (page C-71).
FIGURES-25 Knee-chest position
• If the procedure fails or if the cord prolapses, deliver by

BREECH PRESENTATION
Prolonged labour with breech presentation is an indication for urgent
caesarean section. Failure of labour to progress must be considered a
sign of possible cephalopelvic disproportion (Table S-10, pageS-57).
The frequency of breech presentation is high in preterm

labour.
EARLY LABOUR
Ideally, every breech delivery should take place in a hospital with
surgical capability.
• Attempt external version (page P-15) if:
breech presentation is present at or after 37 weeks (before 37
weeks, a successful version is more likely to spontaneously
revert back to breech presentation);
vaginal delivery is possible;
facilities for emergency caesarian section are available;
membranes are intact and amniotic fluid is adequate;
there are no complications (e.g. fetal growth restriction,
uterine bleeding, previous caesarean delivery, fetal
abnormalities, twin pregnancy, hypertension, fetal death).
If external version is successful, proceed with normal childbirth
(page C-71).
If external version fails, proceed with vaginal breech delivery (see
below) or caesarean section (page P-43).
VAGINAL BREECH DELIVERY
A vaginal breech delivery (page P-37) by a skilled health care
provider is safe and feasible under the following conditions:
complete (Fig S-20, page S-74) or frank breech (Fig S-21,
page S-74);
adequate clinical pelvimetry;

fetus is not too large;
no previous caesarean section for cephalopelvic disproportion;
flexed head.
• Examine the woman regularly and record progress on a partograph
(page C-65).
If the membranes rupture, examine the woman immediately to
exclude cord prolapse.
Note: Do not rupture the membranes.
If the cord prolapses and delivery is not imminent, deliver by
If there are fetal heart rate abnormalities (less than 100 or more
than 180 beats per minute) or prolonged labour, deliver by
Note: Meconium is common with breech labour and is not a sign
of fetal distress if the fetal heart rate is normal.
The woman should not push until the cervix is fully dilated.
Full dilatation should be confirmed by vaginal examination.
CAESAREAN SECTION FOR BREECH PRESENTATION

A caesarean section (page P-43) is safer than vaginal breech
delivery and recommended in cases of:
double footling breech;
small or malformed pelvis;
very large fetus;
previous caesarean section for cephalopelvic disproportion;
hyperextended or deflexed head.
Note: Elective caesarean section does not improve the outcome in
preterm breech delivery.
COMPLICATIONS
Fetal complications of breech presentation include:
cord prolapse;
birth trauma as a result of extended arm or head, incomplete
dilatation of the cervix or cephalopelvic disproportion;
• asphyxia from cord prolapse, cord compression, placental
detachment or entrapped head;
damage to abdominal organs;
broken neck.
TRANSVERSE LIE AND SHOULDER PRESENTATION

• If the woman is in early labour and the membranes are intact,
attempt external version (page P-15):
If external version is successful, proceed with normal
childbirth (page C-71);
If external version fails or is not advisable, deliver by
Monitor for signs of cord prolapse. If the cord prolapses and
delivery is not imminent, deliver by caesarean section (page
P-43).
Note: Ruptured uterus may occur if the woman is left unattended (page
S-20).
In modern practise, persistent transverse lie in labour is

delivered by caesarean section whether the fetus is alive or
dead.
S·82 Malpositions and malpresentations
SHOULDER DYSTOCIA (Stuck shoulders) S-83
PROBLEM
The fetal head has been delivered but the shoulders are stuck and
cannot be delivered.
GENERAL MANAGEMENT
Be prepared for shoulder dystocia at all deliveries, especially if a
large baby is anticipated.
Have several persons available to help.
Shoulder dystocia cannot be predicted.
DIAGNOSIS
The fetal head is delivered but remains tightly applied to the vulva.
• The chin retracts and depresses the perineum.
Traction on the head fails to deliver the shoulder, which is caught
behind the symphysis pubis.
MANAGEMENT
• Make an adequate episiotomy (page P-71) to reduce soft tissue
obstruction and to allow space for manipulation.
• With the woman on her back, ask her to flex both thighs, bringing
her knees as far up as possible towards her chest (Fig S-26, page
S-84). Ask two assistants to push her flexed knees firmly up onto
her chest.
S-84 Shoulder dystocia
FIGURES-26 Assistant pushing flexed knees firmly towards

chest
Wearing high-level disinfected or sterile gloves:

Apply firm, continuous traction downwards on the fetal head
to move the shoulder that is anterior under the symphysis
pubis;
Note: Avoid excessive traction on the fetal head as this may
result in brachial plexus injury;
Have an assistant simultaneously apply suprapubic pressure
downwards to assist delivery of the shoulder;
Note: Do not apply fundal pressure. This will further impact
the shoulder and can result in uterine rupture.
If the shoulder still is not delivered:
Insert a hand into the vagina along the baby's back;
Apply pressure to the shoulder that is anterior in the direction
of the baby's sternum to rotate the shoulder and decrease the
diameter of the shoulders;
If needed, apply pressure to the shoulder that is posterior in the
direction of the sternum.
If the shoulder still is not delivered despite the above measures:
Insert a hand into the vagina;
Shoulder dystocia S-85
Grasp the humerus of the arm that is posterior and, keeping the
arm flexed at the elbow, sweep the arm across the chest. This
will provide room for the shoulder that is anterior to move
under the symphysis pubis (Fig S-27).
FIGURES-27 Grasping the humerus of the arm that is posterior
and sweeping the arm across the chest
If all of the above measures fail to deliver the shoulder, other

options include:
Fracture the clavicle to decrease the width of the shoulders and
free the shoulder that is anterior;
Apply traction with a hook in the axilla to extract the arm that
is posterior.
S-86 Shoulder dystocia
LABOUR WITH AN OVERDISTENDED UTERUS s-s7
PROBLEM
• A woman in labour has an overdistended uterus or symphysis-
fundal height more than expected for the period of gestation.
GENERAL MANAGEMENT
Prop up the woman.
Confirm accuracy of calculated gestational age, if possible.
DIAGNOSIS
• If only one fetus is felt on abdominal examination, consider wrong
dates, a single large fetus (page S-88) or an excess of amniotic
fluid (page S-88).
• If multiple fetal poles and parts are felt on abdominal
examination, suspect multiple pregnancy. Other signs of multiple
pregnancy include:
fetal head small in relation to the uterus;
uterus larger than expected for gestation;
more than one fetal heart heard with Doppler fetal stethoscope.
Note: An acoustic fetal stethoscope cannot be used to confirm
the diagnosis, as one heart may be heard in different areas.
Use ultrasound examination, if available, to:
identify the number, presentations and sizes of fetuses;
assess the volume of amniotic fluid.
• If ultrasound service is not available, perform radiological
examination (anterio-posterior view) for number of fetuses and
presentations.
S-88 Labour with an overdistended uterus
MANAGEMENT
SINGLE LARGE FETUS
Manage as for normal labour (page C-57).
Anticipate and prepare for prolonged and obstructed labour (page
S-57), shoulder dystocia (page S-83) and postpartum haemorrhage
(page S-25).
EXCESS AMNIOTIC FLUID

Allow labour to progress and monitor progress using a partograph
(page C-65).
If the woman is uncomfortable because of uterine distension,
aspirate excess amniotic fluid:
Palpate for location of fetus;
Prepare the skin with an antiseptic (page C-22);
Under aseptic conditions, insert a 20-gauge spinal needle
through the abdominal and uterine walls and withdraw the
stylet;
Aspirate the fluid using a large syringe. Alternatively, attach
an infusion set to the needle and allow the fluid to slowly drain
into a container;
When the woman is no longer uncomfortable because of
overdistension, replace the stylet and remove the needle.
If rupture of membranes is indicated for other reasons, rupture
the membranes with an amniotic hook or a Kocher clamp (page
P-17).
• Check for cord prolapse when membranes rupture. If the cord
prolapses and delivery is not imminent, deliver by caesarean
MULTIPLE PREGNANCY
FIRST BABY
Start an IV infusion and slowly infuse IV fluids (page C-21).
• Monitor fetuses by intermittent auscultation of the fetal heart rates.
If there are fetal heart rate abnormalities (less than I 00 or more
Check presentation:
If a vertex presentation, allow labour to progress as for a
single vertex presentation (page C-57) and monitor progress in
labour using a partograph (page C-65);
If a breech presentation, apply the same guidelines as for a
singleton breech presentation (page S-79) and monitor
progress in labour using a partograph (page C-65);
If a transverse lie, deliver by caesarean section (page P-43).
Leave a clamp on the maternal end of the umbilical cord and

do not attempt to deliver the placenta until the last baby is
delivered.
SECOND OR ADDITIONAL BABY(S)

Immediately after the first baby is delivered:
Palpate the abdomen to determine lie of additional baby;
Correct to longitudinal lie by external version (page P-15);
Check fetal heart rate(s).
Perform a vaginal examination to determine if:
the cord has prolapsed (page S-97);
the membranes are intact or ruptured;
presentation of other baby(s).
VERTEX PRESENTATION
If the fetal head is not engaged, manoeuvre the head into the
pelvis manually (hands on abdomen), if possible.
5-90 Labour with an overdistended uterus
If the membranes are intact, rupture the membranes with an

amniotic hook or a Kocher clamp.
Check fetal heart rate between contractions.
If contractions are inadequate after birth of first baby, augment
labour with oxytocin using rapid escalation (Table P-8, page P-23)
to produce good contractions (three contractions in 10 minutes,
each lasting more than 40 seconds).
• If spontaneous delivery does not occur within two hours of
good contractions or if there are fetal heart rate abnormalities
(less than 100 or more than 180 beats per minute), deliver by
BREECH PRESENTATION
• If the baby is estimated to be no larger than the first baby, and
if the cervix has not contracted, consider breech extraction (page
P-42) or vaginal delivery (page C-71):
If there are inadequate or no contractions after birth of first
baby, escalate oxytocin infusion at a rapid but controlled rate
(Table P-8, page P-23) to produce good contractions (three
contractions in 10 minutes, each lasting more than 40
seconds);
If the membranes are intact and the breech has descended,
rupture the membranes with an amniotic hook or a Kocher
clamp (page P-17);
Check fetal heart rate between contractions. If there are fetal
heart rate abnormalities (less than 100 or more than 180
beats per minute), deliver by breech extraction (page P-42).
If vaginal delivery is not possible, deliver by caesarean section
(page P-43).
TRANSVERSE LIE
If the membranes are intact, attempt external version (page
P-15).
• If external version fails and the cervix is fully dilated and
membranes are still intact, attempt internal podalic version:
Note: Do not attempt internal podalic version if the provider is
untrained, the membranes have ruptured and the amniotic fluid has
drained, or if the uterus is scarred. Do not persist if the baby does
not turn easily.
Wearing high-level disinfected or sterile gloves, insert a hand

into the uterus and grasp the baby's foot;
Gently rotate the baby down;
Proceed with breech extraction (page P-42).
Check fetal heart rate between contractions.
If external version fails and internal podalic version is not
advisable or fails, deliver by caesarean section (page P-43).
Give oxytocin I 0 units IM or give ergometrine 0.2 mg IM within
one minute after delivery of the last baby and continue active
management of the third stage to reduce postpartum blood loss
(page C-73).
COMPLICATIQNS
Maternal complications of multiple pregnancy include:
anaemia;
abortion;
pregnancy-induced hypertension and pre-eclampsia;
excess amniotic fluid;
poor contractions during labour;
retained placenta;
postpartum haemorrhage.
Placental/fetal complications include:
placenta praevia;
abruptio placentae;
placental insufficiency;
preterm delivery;
low birth weight;
malpresentations;
cord prolapse;
congenital anomalies.
S·92 Labour with an overdistended uterus
LABOUR WITH A SCARRED UTERUS S-93
PROBLEM
• A woman in labour has a scarred uterus from a previous uterine
surgery.
GENERAL MANAGEMENT
If possible, identify the reason for the uterine scar. Caesarean
section and other uterine surgeries (e.g. repair of a previous uterine
rupture, excision of an ectopic pregnancy implanted in the cornua)
leave a scar in the uterine wall. This scar can weaken the uterus,
leading to uterine rupture during labour (Box S-6).
BOXS-6 Rupture of uterine scars
• Vertical scars from a previous caesarean section may rupture before

labour or during the latent phase.
• Transverse scars typically rupture during active labour or during the

expulsive phase.
The rupture may extend only a short distance into the myometrium
with little pain or bleeding. The fetus and placenta may remain in the
uterus and the fetus may survive for minutes or hours.
SPECIFIC MANAGEMENT
Studies have shown that more than 50% of cases with low transverse
caesarean scars can deliver vaginally. The frequency of rupture of low
transverse scars during a careful trial of labour is reported as less than
1%.
TRIAL OF LABOUR
Ensure that conditions are favourable for trial of labour, namely:
The previous surgery was a low transverse caesarean incision;
The fetus is in a normal vertex presentation;
S-94 Labour with a scarred uterus
Emergency caesarean section can be carried out immediately

if required.
If these conditions are not met or if the woman has a history of
two lower uterine segment caesarean sections or ruptured
uterus, deliver by caesarean section (page P-43).
Monitor progress of labour using a partograph (page C-65).
If cervical dilatation crosses the alert line of the partograph,
diagnose the cause of slow progress and take appropriate action:
If there is slow progress in labour due to inefficient uterine
contractions (Table S-10, pageS-57), rupture the membranes
with an amniotic hook or a Kocher clamp and augment labour
using oxytocin (page P-17);
If there are signs of cephalopelvic disproportion or
obstruction (Table S-10), deliver immediately by caesarean
• If there are signs of impending uterine rupture (rapid maternal
pulse, persistent abdominal pain and suprapubic tenderness, fetal
distress), deliver immediately by caesarean section (page P-43).
If uterine rupture is suspected, deliver immediately by caesarean
section (page P-43) and repair the uterus (page P-95) or perform
hysterectomy (page P-103).
FETAL DISTRESS IN LABOUR S-95
PROBLEMS
• Abnormal fetal heart rate (less than 100 or more than 180 beats per
minute).
Thick meconium-stained amniotic fluid.
GENERAL MANAGEMENT
Prop up the woman or place her on her left side.
• Stop oxytocin if it is being administered.
• Give oxygen 4-6 L by mask or nasal cannulae.
ABNORMAL FETAL HEART RATE

BOXS-7 Abnormal fetal heart rate
• A normal fetal heart rate may slow during a contraction but usually
recovers to normal as soon as the uterus relaxes.
A very slow fetal heart rate in the absence of contractions or

persisting after contractions is suggestive of fetal distress.
• A rapid fetal heart rate may be a response to maternal fever, drugs

causing rapid maternal heart rate (e.g. terbutaline or ritodrine),
hypertension or amnionitis. In the absence of a rapid maternal heart
rate, a rapid fetal heart rate should be considered a sign of fetal
distress.
• If a maternal cause is identified (e.g. maternal fever, drugs),

initiate appropriate management.
• If a maternal cause is not identified and the fetal heart rate
remains abnormal throughout at least three contractions, perform
a vaginal examination to check for explanatory signs of distress:
If there is bleeding with intermittent or constant pain,
suspect abruptio placentae (page S-18);
S-96 Fetal distress in labour

discharge) give antibiotics as for amnionitis (page S-139);
If the cord is below the presenting part or in the vagina,
manage as prolapsed cord (page S-97).
If fetal heart rate abnormalities persist or there are additional
signs of distress (thick meconium-stained fluid), plan delivery:
If the cervix is fully dilated and the fetal head is not more
than 1/5 above the symphysis pubis or the leading bony edge
of the fetal head is at 0 station, deliver by vacuum extraction
(page P-27) or forceps (page P-33);
If the cervix is not fully dilated or the fetal head is more
than 1/5 above the symphysis pubis or the leading bony edge
of the fetal head is above 0 station, deliver by caesarean
MECONIUM
Meconium staining of amniotic fluid is seen frequently as the fetus
matures and by itself is not an indicator of fetal distress. A slight
degree of meconium without fetal heart rate abnormalities is a
warning of the need for vigilance.
Thick meconium suggests passage of meconium in reduced
amniotic fluid and may indicate the need for expedited delivery
and management of the neonatal upper airway at birth to prevent
meconium aspiration (page S-143).
In breech presentation, meconium is passed in labour because of
compression of the fetal abdomen. This is not a sign of distress
unless it occurs in early labour.
PROLAPSED CORD 5-97
PROBLEMS
The umbilical cord lies in the birth canal below the fetal presenting
part.
The umbilical cord is visible at the vagina following rupture of the
membranes.
GENERAL MANAGEMENT
SPECIFIC MANAGEMENT
PULSATING CORD
If the cord is pulsating, the fetus is alive.
Diagnose stage of labour by an immediate vaginal examination
(Table C-8, page C-60).
• If the woman is in the first stage of labour, in all cases:
Wearing high-level disinfected or sterile gloves, insert a hand
into the vagina and push the presenting part up to decrease
pressure on the cord and dislodge the presenting part from the
pelvis;
Place the other hand on the abdomen in the suprapubic region
to keep the presenting part out of the pelvis;
Once the presenting part is firmly held above the pelvic brim,
remove the other hand from the vagina. Keep the hand on the
abdomen until caesarean section;
If available, give salbutamol 0.5 mg IV slowly over two
minutes to reduce contractions;
Perform immediate caesarean section (page P-43).
If the woman is in the second stage of labour:
Expedite delivery with episiotomy (page P-71) and vacuum
extraction (page P-27) or forceps (page P-33);
S-98 Prolapsed cord
If breech presentation, perform breech extraction (page

P-42) and apply Piper or long forceps to the after-coming head
(page P-41);
Prepare for resuscitation of the newborn (page S-142).
CORD NOT PULSATING

If the cord is not pulsating, the fetus is dead. Deliver in the manner
that is safest for the woman.
FEVER DURING PREGNANCY AND LABOUR s-99
PROBLEM
• A woman has a fever (temperature 38°C or more) during
pregnancy or labour.
GENERAL MANAGEMENT
• Encourage bed rest.
Encourage increased fluid intake by mouth.
• Use a fan or tepid sponge to help decrease temperature.
S-100 Fever during pregnancy and labour
DIAGNOSIS
TABLES-13 Diagnosis of fever during pregnancy and labour

Typically Present
• Dysuria • Retropubic/suprapubic Cystitis, page S-101
Increased frequency and pain
urgency of urination • Abdominal pain
• Dysuria • Retropubic/suprapubic Acute
Spiking fever/chills pain pyelonephritis, page
• Increased frequency and • Loin pain/tenderness S-102
urgency of urination • Tenderness in rib cage
• Abdominal pain • Anorexia
• Nausea/vomiting
• Foul-smelling vaginal • Lower abdominal pain Septic abortion,
discharge in first 22 weeks • Rebound tenderness Table S-2, page S-9
• Fever • Prolonged bleeding
• Tender uterus • Purulent cervical discharge
• Fever/chills • History of loss of fluid Amnionitis, page
• Foul-smelling watery • Tender uterus S-139
discharge after 22 weeks • Rapid fetal heart rate
• Abdominal pain • Light vaginal bleeding
• Fever • Consolidation Pneumonia, page
• Difficulty in breathing • Congested throat S-129
• Cough with expectoration • Rapid breathing
• Chest pain • Rhonchilrales
• Fever • Enlarged spleen Uncomplicated
• Chills/rigors malaria, page S-103
• Headache
• Muscle/joint pain
• Symptoms and signs of • Convulsions Severe/complicated
uncomplicated malaria • Jaundice malaria, page S-52
• Coma
• Anaemia
• Fever • Confusion Typhoid"
• Headache • Stupor
• Dry cough
• Malaise
• Anorexia
• Enlarged spleen
• Give ampicillin 1 g by mouth four times per day OR give amoxicillin 1 g by mouth
three times per day for 14 days. Alternative therapy will depend on local sensitivity
patterns.
Fever during pregnancy and labour 5-101
TABLE S-13 Cont. Diagnosis of fever during pregnancy and labour

Typically Present
• Fever • Muscle/joint pain Hepatitisb
• Malaise • Urticaria
• Anorexia • Enlarged spleen
• Nausea
• Dark urine and pale stool
• Jaundice
• Enlarged liver
b Provide supportive therapy and observe.
MANAGEMENT
URINARY TRACT INFECTIONS
Assume that a urinary tract infection involves all levels of the

tract, from renal calyces to urethral meatus.
TESTS
Dipstick, microscopy and urine culture tests can be used to determine if
a urinary tract infection is present, but will not differentiate between
cystitis and acute pyelonephritis.
A dipstick leukocyte esterase test can be used to detect white blood
cells, and a nitrate reductase test can be used to detect nitrites.
• Microscopy of urine specimen may show white cells in clumps,
bacteria and sometimes red cells.
Urine culture and sensitivity tests should be done, if available, to
identify the organism and its antibiotic sensitivity.
Note: Urine examination requires a clean-catch mid-stream specimen to
minimize the possibility of contamination.
CYSTITIS
Cystitis is infection of the bladder.
• Treat with antibiotics (page C-35):
S·102 Fever during pregnancy and labour
amoxicillin 500 mg by mouth three times per day for three

days;
OR trimethoprim/sulfamethoxazole one tablet (160/800 mg)
by mouth two times per day for three days.
If treatment fails, check urine culture and sensitivity, if available,
and treat with an antibiotic appropriate for the organism.
• If infection recurs two or more times:
Check urine culture and sensitivity, if available, and treat with
an antibiotic appropriate for the organism;
For prophylaxis against further infections, give antibiotics by
mouth once daily at bedtime for the remainder of pregnancy
and two weeks postpartum. Give:
trimethoprim/sulfamethoxazole one tablet (160/800 mg);
OR amoxicillin 250 mg.
Note: Prophylaxis is indicated after recurrent infections, not
after a single episode.
ACUTE PYELONEPHRITIS
Acute pyelonephritis is an infection of the upper urinary tract, mainly
of the renal pelvis, which may also involve the renal parenchyma.
• If shock is present or suspected, initiate immediate treatment
(page S-1).
• Start an IV infusion and infuse IV fluids at 150 mL per hour (page
C-21).
• Check urine culture and sensitivity, if possible, and treat with an
antibiotic appropriate for the organism.
• If urine culture is unavailable, treat with antibiotics until the
woman is fever-free for 48 hours (page C-35):
PLUS gentamicin 5 mg/kg body weight IV every 24 hours.
• Once the woman is fever-free for 48 hours, give amoxicillin 1 g
by mouth three times per day to complete 14 days of treatment.
Note: Clinical response is expected within 48 hours. If there is no
clinical response in 72 hours, re-evaluate results and antibiotic
coverage.
For prophylaxis against further infections, give antibiotics by

mouth once daily at bedtime for the remainder of pregnancy and
for two weeks postpartum. Give:
trimethoprim/sulfamethoxazole one tablet (160/800 mg);
OR amoxicillin 250 mg.
Ensure adequate hydration by mouth or IV.
Give paracetamol 500 mg by mouth as needed for pain and to
lower temperature.
If there are palpable contractions and blood-stained mucus
discharge, suspect preterm labour (page S-122).
UNCOMPLICATED MALARIA
Two species of malaria parasites, Plasmodium. falciparum and P. vivax,
account for the majority of cases. Symptomatic falciparum malaria in
pregnant women may cause severe disease and death if not recognized
and treated early. When malaria presents as an acute illness with fever,
it cannot be reliably distinguished from many other causes of fever on
clinical grounds. Malaria should be considered the most likely
diagnosis in a pregnant woman with fever who has been exposed to
malaria.
Women without pre-existing immunity to malaria (living in non-
malarial area) are susceptible to the more severe complications of
malaria (page S-52).
Women with acquired immunity to malaria are at high risk for
developing severe anaemia and delivering low birth weight babies.
TESTS
If facilities for testing are not available, begin therapy with
antimalarial drugs based on clinical suspicion (e.g. headache, fever,
joint pain).
Where available, the following tests will confirm the diagnosis:
microscopy of a thick and thin blood film:
thick blood film is more sensitive at detecting parasites
(absence of parasites does not rule out malaria);
thin blood film helps to identify the parasite species.
rapid antigen detection tests.
5·104 Fever during pregnancy and labour
FALCIPARUM MALARIA
ACUTE, UNCOMPLICATED P. FALCIPARUM MALARIA
Chloroquine-resistant falciparum malaria is widespread. Resistance to
other drugs (e.g. quinine, sulfadoxine/pyrimethamine, mefloquine) also
occurs. It is, therefore, important to follow the recommended national
treatment guidelines. Drugs contraindicated in pregnancy include
primaquine, tetracycline, doxycycline and halofantrine. Insufficient
data currently exists on the use of atovoquone/proguanil and
artemether/lumefantrine in pregnancy to recommend their use at this
time.
AREA OF CHLOROQUINE-SENSITIVE P. FALCIPARUM PARASITES
• Give chloroquine base 10 mg/kg body weight by mouth once daily
for two days followed by 5 mg/kg body weight on day 3.
Note: Chloroquine is considered safe in all three trimesters of
pregnancy.
AREA OF CHLOROQUINE-RESISTANT P. FALCIPARUM PARASITES
Oral sulfadoxine/pyrimethamine or quinine salt (dihydrochloride or
sulfate) can be used for treating chloroquine-resistant malaria
throughout pregnancy. Treatment options include:
sulfadoxine/pyrimethamine three tablets by mouth as a single dose;
Note: Sulfadoxine/pyrimethamine should not be used if the woman
is allergic to sulfonamides.
• OR quinine salt 10 mg/kg body weight by mouth three times per
day for seven days.
Note: If compliance with seven days of quinine is not possible or
side effects are severe, give a minimum of three days of quinine
PLUS sulfadoxine/pyrimethamine three tablets by mouth as a
single dose on the first day of treatment (providing
sulfadoxine/pyrimethamine is effective; consult the national
guidelines).
Mefloquine may also be used for treating symptomatic P. falciparum in
pregnancy if treatment with quinine or sulfadoxine/pyrimethamine is
unsuitable because of drug resistance or individual contraindications.
Note: Clinicians should carefully consider the use of mefloquine in
early pregnancy due to limited safety data in the first trimester of
pregnancy:
In areas of mefloquine-sensitive parasites, give mefloquine 15

mg/kg body weight by mouth as a single dose;
In areas of emerging mefloquine resistance, give mefloquine 15
mg/kg body weight by mouth followed by 10 mg/kg body weight
24 hours later.
AREA OF MULTIDRUG-RESISTANT P. FALCIPARUM MALARIA
Multidrug-resistant P. falciparum malaria (resistant to chloroquine and
sulfadoxine/pyrimethamine and quinine or mefloquine) is present in
certain areas limiting treatment options. Consult the national treatment
guidelines. Treatment options include:
quinine salt (dihydrochloride or sulfate) 10 mg/kg body weight by
mouth three times daily for seven days;
OR quinine salt 10 mg/kg body weight by mouth three times daily
for even days PLUS clindamycin 300 mg four times daily for five
days;
Note: The quinine/clindamycin combination can be used in areas
of quinine resistance.
OR artesunate 4 mg/kg body weight by mouth in a divided loading
dose on day 1, followed by 2 mg/kg body weight by mouth once
daily for six days.
Note: Artesunate can be used in the second and third trimester for
treating uncomplicated malaria but there are insufficient data to
recommend its use in the first trimester. Artesunate may be used,
however, if no suitable alternative exists.
VIVAX MALARIA
AREA OF CHLOROQUINE-SENSITIVE P. VIVAX PARASITES
Chloroquine alone is the treatment of choice in areas with chloroquine-
sensitive vivax malaria and areas with chloroquine-sensitive vivax and
falciparum malaria. Where there is chloroquine-resistant P. falciparum,
manage as a mixed infection (page S-106).
Give chloroquine base 10 mg/kg body weight by mouth once daily
for two days followed by 5 mg/kg body weight by mouth on day 3.
AREA OF CHLOROQUINE-RESISTANT P. VIVAX PARASITES
Chloroquine-resistant P. vivax has been reported in several countries
and there are limited data available to determine the optimal treatment.
Before considering second line drugs for treatment failure with
chloroquine, clinicians should exclude poor patient compliance and a
S-106 Fever during pregnancy and labour
new infection with P. falciparum. If diagnostic testing is not

available, manage as a mixed infection (see below). Treatment options
for confirmed chloroquine-resistant vivax malaria include:
quinine salt (dihydrochloride or sulfate) 10 mg/kg body weight by
mouth twice daily for seven days;
Note: The dose of quinine is less than that used for falciparum
malaria; diagnosis of species is essential.
OR mefloquine 15 mg/kg body weight by mouth as a single dose;
OR sulfadoxine/pyrimethamine three tablets by mouth as a single
dose;
Note: Sulfadoxine/pyrimethamine is not generally recommended
because it acts slowly to clear vivax parasites.
OR artesunate 4 mg/kg body weight by mouth in a divided loading
dose on day I followed by 2 mg/kg body weight by mouth daily
for six days.
TREATMENT OF LIVER STAGES OF VIVAX MALARIA
Vivax malaria may remain dormant in the liver. From time to time,
these dormant stages are released into the blood to cause a new,
symptomatic vivax infection. Primaquine can be used to clear the liver
stages but its use is not acceptable during pregnancy; primaquine
should be used only after delivery. Dose regimens vary by geographic
region; use the dose recommended in the national guidelines.
AREAS OF MIXED FALCIPARUM-VIVAX MALARIA
In areas of mixed transmission, the proportions of malaria species and
their drug sensitivity patterns vary. Referral to the national treatment
guidelines is essential. If microscopic diagnosis is available, specific
treatment can be prescribed. Where unavailable, options include:
assume the infection is due to P. falciparum and treat accordingly
(follow national guidelines);
in areas of chloroquine-resistant but sulfadoxine/pyrimethamine
sensitive P. falciparum and chloroquine sensitive P. vivax, treat
with standard dose chloroquine and standard dose sulfadoxine/
pyrimethamine.
FEVER AFTER CHILDBIRTH 5·107
PROBLEM
A woman has a fever (temperature 38°C or more) occurring more
than 24 hours after delivery.
GENERAL MANAGEMENT
Encourage bed rest.
Ensure adequate hydration by mouth or IV.
Use a fan or tepid sponge to help decrease temperature.
S-108 Fever after childbirth
DIAGNOSIS
TABLES-14 Diagnosis of fever after childbirth

Typically Present
• Fever/chills • Light• vaginal bleeding Metritis, page S-110
• Lower abdominal pain • Shock
• Purulent, foul-smelling lochia
• Tender uterus
• Lower abdominal pain and • Poor response to Pelvic abscess, page
distension antibiotics S-110
• Persistent spiking fever/chills • Swelling in adnexa or
• Tender uterus pouch of Douglas
• Pus obtained upon
culdocentesis
• Low-grade fever/chills • Rebound tenderness Peritonitis, page S-111
• Lower abdominal pain • Abdominal distension
• Absent bowel sounds • Anorexia
• Nausea/vomiting
• Shock
• Breast pain and tenderness • Hard enlarged breasts Breast engorgement,
• 3-5 days after delivery • Both breasts affected page S-111
• Breast pain and tenderness • Inflammation preceded Mastitis, page S-112
• Reddened, wedge-shaped by engorgement
area on breast • Usually only one breast
• 3-4 weeks after delivery affected
• Firm, very tender breast • Fluctuant swelling in Breast abscess, page
• Overlying erythema breast S-113
• Draining pus
• Unusually tender wound with • Slight erythema Wound abscess,
bloody or serous discharge extending beyond edge wound seroma or
of incision wound haematoma,
page S-113
• Painful and tender wound • Hardened wound Wound cellulitis, page
• Erythema and oedema • Purulent discharge S-114
beyond edge of incision • Reddened area around
wound
• Increased frequency and pain
urgency of urination • Abdominal pain
a Light bleeding: takes longer than five minutes for a clean pad or cloth to be
soaked.
TABLE S-14 Cont. Diagnosis of fever after childbirth

Typically Present
• Dysuria • Retropubic/suprapubic Acute pyelonephritis,
• Spiking fever/chills pain page S-102
• Increased frequency and • Loin pain/tenderness
• Nausea/vomiting
• Spiking fever despite • Calf muscle tenderness Deep vein thrombosis•
antibiotics
• Fever • Consolidation Pneumonia, page
• Difficulty in breathing • Congested throat S-129
• Chest pain • Rhonchilrales
• Fever • Typically occurs Atelectasisb
• Decreased breath sounds postoperative
• Fever • Enlarged spleen Uncomplicated
• Chills/rigors malaria, page S-103
• Headache
• Muscle/joint pain
• Symptoms and signs of • Convulsions Severe/complicated
uncomplicated malaria • Jaundice malaria, page S-52
• Coma
• Anaemia
• Fever • Confusion Typhoid<
• Headache • Stupor
• Dry cough
• Malaise
• Anorexia
• Enlarged spleen
• Fever • Muscle/joint pain Hepatitisd
• Malaise • Urticaria
• Anorexia • Enlarged spleen
• Nausea
• Dark urine and pale stool
• Jaundice
• Enlarged liver
• Give heparin infusion.
b Encourage the woman to move about freely and breathe deeply. Antibiotics are not
necessary.
c Give ampicillin 1 g by mouth four times per day OR amoxicillin 1 g by mouth three
times per day for 14 days. Alternative therapy will depend on local sensitivity patterns.
d Provide supportive therapy and observe.
MANAGEMENT
METRITIS
Metritis is infection of the uterus after delivery and is a major cause of
maternal death. Delayed or inadequate treatment of metritis may result
in pelvic abscess, peritonitis, septic shock, deep vein thrombosis,
pulmonary embolism, chronic pelvic infection with recurrent pelvic
pain and dyspareunia, tubal blockage and infertility.
Transfuse as necessary. Use packed cells, if available (page C-23).
Give a combination of antibiotics until the woman is fever-free for
48 hours (page C-35):
PLUS gentamicin 5 mg/kg body weight IV every 24 hours;
PLUS metronidazole 500 mg IV every eight hours;
If fever is still present 72 hours after starting antibiotics,
re-evaluate and revise diagnosis.
Note: Oral antibiotics are not necessary after stopping IV
antibiotics.
If retained placental fragments are suspected, perform a digital
exploration of the uterus to remove clots and large pieces. Use
ovum forceps or a wide curette if required.
If there is no improvement with conservative measures and there
are signs of general peritonitis (fever, rebound tenderness,
abdominal pain), perform a laparotomy to drain the pus.
• If the uterus is necrotic and septic, perform subtotal hysterectomy
(page P-103).
PELVIC ABSCESS
Give a combination of antibiotics before draining the abscess and
continue until the woman is fever-free for 48 hours (page C-35):
If the abscess is fluctuant in the cui-de-sac, drain the pus through

the cui-de-sac (page P-69). If the spiking fever continues,
perform a laparotomy.
PERITONITIS
Provide nasogastric suction.
Give a combination of antibiotics until the woman is fever-free for
If necessary, perform laparotomy for peritoneal lavage (wash-out).
BREAST ENGORGEMENT
Breast engorgement is an exaggeration of the lymphatic and venous
engorgement that occurs before lactation. It is not the result of
overdistension of the breast with milk.
BREASTFEEDING
If the woman is breastfeeding and the baby is not able to suckle,
encourage the woman to express milk by hand or with a pump.
If the woman is breastfeeding and the baby is able to suckle:
Encourage the woman to breastfeed more frequently, using
both breasts at each feeding;
Show the woman how to hold the baby and help it attach;
Relief measures before feeding may include:
Apply warm compresses to the breasts just before
breastfeeding, or encourage the woman to take a warm
shower;
Massage the woman's neck and back;
Have the woman express some milk manually before
breastfeeding and wet the nipple area to help the baby
latch on properly and easily;
Relief measures after feeding may include:

Support breasts with a binder or brassiere;
Apply cold compress to the breasts between feedings to
reduce swelling and pain;
Give paracetamol 500 mg by mouth as needed;
Follow up in three days to ensure response.
NOT BREASTFEEDING
If the woman is not breastfeeding:
Support breasts with a binder or brassiere;
Apply cold compresses to the breasts to reduce swelling and
pain;
A void massaging or applying heat to the breasts;
Avoid stimulating the nipples;
Give paracetamol 500 mg by mouth as needed;
BREAST INFECTION
MASTITIS
Treat with antibiotics (page C-35):
cloxacillin 500 mg by mouth four times per day for lO days;
OR erythromycin 250 mg by mouth three times per day for 10
days.
Encourage the woman to:
continue breastfeeding;
support breasts with a binder or brassiere;
apply cold compresses to the breasts between feedings to
reduce swelling and pain.
Give paracetamol 500 mg by mouth as needed.
BREAST ABSCESS
Treat with antibiotics (page C-35):
cloxacillin 500 mg by mouth four times per day for 10 days;
OR erythromycin 250 mg by mouth three times per day for 10
days.
• Drain the abscess:
General anaesthesia (e.g. ketamine, page P-13) is usually
required;
Make the incision radially, extending from near the areolar
margin towards the periphery of the breast to avoid injury to
the milk ducts;
Wearing high-level disinfected gloves or sterile, use a finger
or tissue forceps to break up the pockets of pus;
Loosely pack the cavity with gauze;
Remove the gauze pack after 24 hours and replace with a
smaller gauze pack.
If there is still pus in the cavity, place a small gauze pack in the
cavity and bring the edge out through the wound as a wick to
facilitate drainage of any remaining pus.
Encourage the woman to:
continue breastfeeding even when there is collection of pus;
support breasts with a binder or brassiere;
apply cold compresses to the breasts between feedings to
reduce swelling and pain.
INFECTION OF PERINEAL AND ABDOMINAL WOUNDS
WOUND ABSCESS, WOUND SEROMA AND WOUND HAEMATOMA

If there is pus or fluid, open and drain the wound.
• Remove infected skin or subcutaneous sutures and debride the
wound. Do not remove fascial sutures.
If there is an abscess without cellulitis, antibiotics are not

required.
Place a damp dressing in the wound and have the woman return to
change the dressing every 24 hours.
• Advise the woman on the need for good hygiene and to wear clean
pads or cloths that she changes often.
WOUND CELLULITIS AND NECROTIZING FASCIITIS

If there is fluid or pus, open and drain the wound.
Remove infected skin or subcutaneous sutures and debride the
wound. Do not remove fascial sutures.
If infection is superficial and does not involve deep tissues,
monitor for development of an abscess and give a combination of
antibiotics (page C-35):
ampicillin 500 mg by mouth four times per day for five days;
PLUS metronidazole 400 mg by mouth three times per day for
five days.
• If the infection is deep, involves muscles and is causing necrosis
(necrotizing fasciitis), give a combination of antibiotics until
necrotic tissue has been removed and the woman is fever-free for
penicillin G 2 million units IV every six hours;
Once the woman is fever-free for 48 hours, give:
ampicillin 500 mg by mouth four times per day for five
days;
PLUS metronidazole 400 mg by mouth three times per
day for five days.
Note: Necrotizing fasciitis requires wide surgical debridement.
Perform delayed primary closure two to four weeks later,
depending on resolution of infection.
If the woman has a severe infection or necrotizing fasciitis,
admit her to the hospital for management and change wound
dressing twice daily.
ABDOMINAL PAIN IN EARLY PREGNANCY S-115
PROBLEM
The woman is experiencing abdominal pain in the first 22 weeks of
pregnancy. Abdominal pain may be the first presentation in serious
complications such as abortion or ectopic pregnancy.
GENERAL MANAGEMENT
temperature).
Note: Appendicitis should be suspected in any woman having
abdominal pain. Appendicitis can be confused with other more
common problems in pregnancy which cause abdominal pain (e.g.
ectopic pregnancy, abruptio placentae, twisted ovarian cysts,
pyelonephritis).
S-116 Abdominal pain in early pregnancy
DIAGNOSIS
TABLES-IS Diagnosis of abdominal pain in early pregnancy

Typically Present
• Abdominal pain • Palpable, tender discrete Ovarian cyst", page
• Adnexal mass on vaginal mass in lower abdomen S-117
examination Lightb vaginal bleeding
• Lower abdominal pain • Abdominal distension Appendicitis, page
• Low-grade fever • Anorexia S-117
• Rebound tenderness • Nausea/vomiting
• Paralytic ileus
• Increased white blood
cells
• No mass in lower
abdomen
• Site of pain higher than
ex ected
Increased frequency and pain
urgency of urination
• Abdominal pain
• Dysuria • Retropubic/suprapubic Acute pyelonephritis,
Spiking fever/chills pain page S-102
• Increased frequency and • Loin pain/tenderness
• Nausea/vomiting
• Low-grade fever/chills • Rebound tenderness Peritonitis, page S-111
• Lower abdominal pain • Abdominal distension
• Nausea/vomiting
• Shock
• Abdominal pain • Fainting Ectopic pregnancy,
• Light bleeding • Tender adnexal mass page S-13
• Closed cervix • Amenorrhoea
• Uterus slightly larger than • Cervical motion
normal tenderness
• Uterus softer than normal
• Ovarian cysts may be asymptomatic and are sometimes first detected on physical
examination.
b Light bleeding: takes longer than five minutes for a clean pad or cloth to be
soaked.
Abdominal pain in early pregnancy S-117
MANAGEMENT
OVARIAN CYSTS
Ovarian cysts in pregnancy may cause abdominal pain due to torsion or
rupture. Ovarian cysts most commonly undergo torsion and rupture
during the first trimester.
If the woman is in severe pain, suspect torsion or rupture. Perform
immediate laparotomy.
Note: If findings at laparotomy are suggestive of malignancy
(solid areas in the tumour, growth extending outside the cyst wall),
the specimen should be sent for immediate histological
examination and the woman should be referred to a tertiary care
centre for evaluation and management.
If the cyst is more than 10 cm and is asymptomatic:
If it is detected during the first trimester, observe for growth
or complications;
If it is detected during the second trimester, remove by
laparotomy to prevent complications.
If the cyst is between 5 and 10 cm, follow up. Laparotomy may be
required if the cyst increases in size or fails to regress.
If the cyst is less than 5 cm, it will usually regress on its own and
does not require treatment.
APPENDICITIS
Give a combination of antibiotics before surgery and continue until
the woman is postoperative and fever-free for 48 hours (page
C-35):
• Perform an immediate surgical exploration (regardless of stage of
gestation) and perform appendectomy, if required.
Note: Delaying diagnosis and treatment can result in rupture of the
appendix, which may lead to generalized peritonitis.
S-118 Abdominal pain in early pregnancy
If there are signs of peritonitis (fever, rebound tenderness,

abdominal pain), give antibiotics as for peritonitis (page S-111).
Note: The presence of peritonitis increases the likelihood of
abortion or preterm labour.
If the woman is in severe pain, give pethidine 1 mg/kg body
weight (but not more than 100 mg) IM or IV slowly or give
morphine 0.1 mg!kg body weight IM.
Tocolytic drugs may be needed to prevent preterm labour (Table
S-17, page S-123).
ABDOMINAL PAIN IN LATER PREGNANCY S-119
AND AFTER CHILDBIRTH
PROBLEMS
The woman is experiencing abdominal pain after 22 weeks of
pregnancy.
The woman is experiencing abdominal pain during the first six
weeks after childbirth.
GENERAL MANAGEMENT
temperature).
Note: Appendicitis should be suspected in any woman having
abdominal pain. Appendicitis can be confused with other more
common problems in pregnancy which cause abdominal pain. If
appendicitis occurs in late pregnancy, the infection may be walled off
by the gravid uterus. The size of the uterus rapidly decreases after
delivery, allowing the infection to spill into the peritoneal cavity. In
tpese cases, appendicitis presents as generalized peritonitis.
S-120 Abdominal pain in later pregnancy and after childbirth
DIAGNOSIS
TABLES-16 Diagnosis of abdominal pain in later pregnancy
and after childbirth

Typically Present
• Palpable contractions • Cervical dilatation and Possible preterm
• Blood-stained mucus effacement labour, page S-122
discharge (show) or watery • Light• vaginal bleeding
discharge before 37 weeks
• Palpable contractions • Cervical dilatation and Possible term
• Blood-stained mucus effacement labour, page C-57
discharge (show) or watery • Light vaginal bleeding
discharge at or after 37
weeks
• Intermittent or constant • Shock Abruptio placentae,
abdominal pain • Tense/tender uterus page S-18
• Bleeding after 22 weeks • Decreased/absent fetal
gestation (may be retained in movements
the uterus) • Fetal distress or absent
fetal heart sounds
• Severe abdominal pain (may • Shock Ruptured uterus,
decrease after rupture) • Abdominal distension/ page S-20
• Bleeding (intra-abdominal free fluid
and/or vaginal) • Abnormal uterine contour
• Tender abdomen
• Easily palpable fetal parts
• Absent fetal movements
and fetal heart sounds
• Rapid maternal pulse
• Abdominal pain • History of loss of fluid Amnionitis, page
• Foul-smelling watery vaginal • Tender uterus S-139
discharge after 22 weeks • Rapid fetal heart rate
gestation • Light vaginal bleeding
• Fever/chills
• Abdominal pain • Retropubic/suprapubic Cystitis, page S-101
Dysuria pain
• Increased frequency and
urgency of urination
• Light bleeding: takes five minutes or longer for a clean pad or cloth to be soaked.
TABLE S-16 Cont. Diagnosis of abdominal pain in later pregnancy

and after childbirth
Typically Present
• Dysuria • Retropubic/suprapubic Acute
Abdominal pain pain pyelonephritis, page
• Spiking fever/chills • Loin pain/tenderness S-102
• Increased frequency and • Tenderness in rib cage
urgency of urination • Anorexia
• Nausealvomiting
• Lower abdominal pain • Abdominal distension Appendicitis, page
• Low-grade fever • Anorexia S-117
• Rebound tenderness • Nausea/vomiting
• Paralytic ileus
• Increased white blood
cells
• No mass in lower
abdomen
• Site of pain higher than
ex ected
• Lower abdominal pain • Light vaginal bleeding Metritis, page S-110
• Fever/chills • Shock
• Purulent, foul-smelling
lochia
• Tender uterus
• Lower abdominal pain and • Poor response to Pelvic abscess, page
distension antibiotics S-110
• Persistent spiking fever/ • Swelling in adnexa or
chills pouch of Douglas
• Tender uterus • Pus obtained upon
culdocentesis
• Lower abdominal pain • Rebound tenderness Peritonitis, page
• Low-grade fever/chills • Abdominal distension S-111
• Nausea/vomiting
• Shock
• Abdominal pain • Palpable, tender discrete Ovarian cyst\ page
• Adnexal mass on vaginal mass in lower abdomen S-117
examination Light vaginal bleeding
b Ovarian cysts may be asymptomatic and are sometimes first detected on physical
examination.
PRETERM LABOUR
Preterm delivery is associated with higher perinatal morbidity and
mortality. Management of preterm labour consists of tocolysis (trying
to stop uterine contractions) or allowing labour to progress. Maternal
problems are chiefly related to interventions carried out to stop
contractions (see below).
Make every effort to confirm the gestational age of the fetus.
TOCOLYSIS
This intervention aims to delay delivery until the effect of
corticosteroids has been achieved (see below).
Attempt tocolysis if:
gestation is less than 37 weeks;
the cervix is less than 3 cm dilated;
there is no amnionitis, pre-eclampsia or active bleeding;
there is no fetal distress.
Confirm the diagnosis of preterm labour by documenting cervical
effacement or dilatation over two hours.
If less than 34 weeks gestation, give corticosteroids to the mother
to improve fetal lung maturity and chances of neonatal survival:
betamethasone 12 mg IM, two doses 24 hours apart;
OR dexamethasone 6 mg IM, four doses 12 hours apart.
Note: Corticosteroids should not be used in the presence of frank
infection.
Give a tocolytic drug (Table S-17) and monitor maternal and fetal
condition (pulse, blood pressure, signs of respiratory distress,
uterine contractions, loss of amniotic fluid or blood, fetal heart
rate, fluid balance, blood glucose, etc.).
Note: Do not give tocolytic drugs for more than 48 hours.
If preterm labour continues despite use of tocolytic drugs,

arrange for the baby to receive care at the most appropriate
service with neonatal facilities. If possible, refer the woman
before she gives birth.
TABLE S-17 Tocolytic drugs" to stop uterine contractions
Drug Initial Dose Subsequent Dose Side Effects and

Precautions
Salbutamol 10 mg in 1 If contractions If maternal pulse
L IV fluids. persist, increase increases (more than
Start IV infusion rate by 10 120 per minute),
infusion at drops per minute reduce infusion rate;
10 drops per every 30 minutes If the woman is
minute. until contractions anaemic, use with
stop or maternal caution.
pulse exceeds 120
per minute. If steroids and
salbutamol are used,
If contractions stop, maternal pulmonary
maintain the same oedema may occur.
infusion rate for at Restrict fluids,
least eight hours maintain fluid balance
after the last and stop drug.
contraction.
Indomethacin 100mg Give 25 mg every If gestation is more
loading dose six hours for 48 than 32 weeks, avoid
by mouth or hours use to prevent
rectum premature closure of
fetal ductus arteriosus.
Do not use for more
than 48 hours.
a Alternative drugs include terbutaline, nifedipine and ritodrine.
ALLOWING LABOUR TO PROGRESS

Allow labour to progress if:
gestation is more than 37 weeks;
the cervix is more than 3 cm dilated;
there is active bleeding;
the fetus is distressed, dead or has an anomaly incompatible
with survival;
there is amnionitis or pre-eclampsia.

Monitor progress of labour using the partograph (page C-65).
If labour continues and gestation is less than 37 weeks, give
prophylactic antibiotics (page C-35) in order to help reduce Group
B streptococcus infection in the neonate:
penicillin G 2 million units IV every six hours until delivery;
OR ampicillin 2 g IV every six hours.
Note: Avoid delivery by vacuum extraction, as the risks of
intracranial bleeding in the preterm baby are high.
• Prepare for management of preterm or low birth weight baby and
anticipate the need for resuscitation (page S-141).
DIFFICULTV IN BREATHING S·125
PROBLEM
A woman is short of breath during pregnancy, labour or after
delivery.
GENERAL MANAGEMENT
temperature).
Prop up the woman on her left side.
• Start an IV infusion and infuse IV fluids (page C-21).
• Obtain haemoglobin estimates using haemoglobinometer or other
simple method.
S-126 Difficulty in breathing
DIAGNOSIS
TABLES-18 Diagnosis of difficulty in breathing

Typically Present
• Difficulty in breathing • Lethargy and fatigue Severe anaemia,
• Pallor of conjunctiva, tongue, • Flat or concave nails page S-127
nail beds and/or palms
• Haemoglobin 7g per dL or
less
• Haematocrit 20% or less
• Symptoms and signs of • Oedema Heart failure due to
severe anaemia • Cough anaemia, page
• Rales S-127
• Swelling of legs
• Enlarged liver
• Prominent neck veins
• Difficulty in breathing • Irregular heart beat Heart failure due to
• Diastolic murmur and/or • Enlarged heart heart disease, page
• Harsh systolic murmur with • Rales S-128
palpable thrill • Cyanosis (blueness)
• Cough
• Swelling of legs
• Enlarged liver
• Prominent neck veins
• Difficulty in breathing • Consolidation Pneumonia, page
• Fever • Congested throat S-129
• Chest pain • Rhonchi/rales
• Difficulty in breathing • Cough with expectoration Bronchial asthma,
• Wheezing • Rhonchi/rales page S-129
• Difficulty in breathing • Rales Pulmonary oedema

• Hypertension • Frothy cough associated with pre-
• Proteinuria eclampsia"
• Withhold fluids and give frusemide 40 mg IV once (page S-44).
Difficulty in breathing S·127
MANAGEMENT
SEVERE ANAEMIA
Transfuse as necessary (page C-23):
Use packed cells;
If blood cannot be centrifuged, let the bag of blood hang
until the cells have settled. Infuse the cells slowly and dispose
of the remaining serum;
Give frusemide 40 mg IV with each unit of packed cells.
If Plasmodium falciparum malaria is suspected, manage as
severe malaria (page S-52).
Give ferrous sulfate or ferrous fumerate 120 mg by mouth PLUS
folic acid 400 mcg by mouth once daily for six months during
pregnancy. Continue for three months postpartum.
• Where hookworm is endemic (prevalence of 20% or more), give
one of the following anthelmintic treatments:
albendazole 400 mg by mouth once;
OR mebendazole 500 mg by mouth once or 100 mg two times
per day for three days;
OR levarnisole 2.5 mg/kg body weight by mouth once daily
for three days;
OR pyrantel 10 mg/kg body weight by mouth once daily for
three days.
• If hookworm is highly endemic (prevalence of 50% or more),
repeat the anthelmintic treatment 12 weeks after the first dose.
HEART FAILURE
HEART FAILURE DUE TO ANAEMIA

Transfusion is almost always necessary in heart failure due to
anaemia (page C-23):
Use packed or sedimented cells as described for severe
anaemia (above);
Give frusemide 40 mg IV with each unit of packed cells.
HEART FAILURE DUE TO HEART DISEASE

Treat acute heart failure. Drugs used may include:
morphine 10 mg IM as a single dose;
OR frusemide 40 mg IV, repeated as necessary;
OR digoxin 0.5 mg IM as a single dose;
OR nitroglycerine 0.3 mg under the tongue, repeated in 15
minutes, if necessary.
• Refer to a higher level if needed.
MANAGEMENT OF HEART FAILURE DURING LABOUR

Prop up the woman on her left side.
Limit infusion of IV fluids to decrease the risk of circulatory
overload, and maintain a strict fluid balance chart.
• Ensure adequate analgesia (page C-37).
If oxytocin infusion is required, use a higher concentration at a
slower rate while maintaining a fluid balance chart (e.g. the
concentration may be doubled if the drops per minute is decreased
by half, Table P-7, page P-22).
Note: Do not give ergometrine.
• Have the woman avoid sustained bearing down efforts during the
expulsive stage, if possible.
• If necessary to decrease the woman's workload during
delivery, perform an episiotomy (page P-71) and assist delivery by
vacuum extraction (page P-27) or forceps (page P-33).
Ensure active management ofthird stage (page C-73).
Heart failure is not an indication for caesarean section.
MANAGEMENT OF HEART FAILURE DURING CAESAREAN SECTION

Use local anaesthesia with conscious sedation (page P-7). Avoid
spinal anaesthesia.
Deliver baby and placenta (page P-43).
Difficulty in breathing S-129
PNEUMONIA
Inflammation in pneumonia affects the lung parenchyma and involves
respiratory bronchioles and alveoli. There is loss of lung capacity that is
less tolerated by pregnant women.
A radiograph of the chest may be required to confirm the diagnosis
of pneumonia.
Give erythromycin 500 mg by mouth four times per day for seven
days.
Give steam inhalation.
Consider the possibility of tuberculosis in areas where it is prevalent.
BRONCHIAL ASTHMA
Bronchial asthma complicates 3-4% of pregnancies. Pregnancy is
associated with worsening of the symptoms in one-third of affected
women.
If bronchospasm occurs, give bronchodilators (e.g. salbutamol4
mg by mouth every four hours OR 250 mcg aerosol every 15
minutes for three doses).
If there is no response to bronchodilators, give corticosteroids
such as hydrocortisone IV 2 mg/kg body weight every four hours
as needed.
• If there are signs of infection (bronchitis), give ampicillin 2 g IV
every six hours.
A void the use of prostaglandins. For prevention and treatment of
postpartum haemorrhage, give oxytocin 10 units IM or give
ergometrine 0.2 mg IM.
After acute exacerbation has been managed, continue treatment
with inhaled bronchodilators and inhaled corticosteroids to prevent
recurrent acute episodes.
LOSS OF FETAL MOVEMENTS S-131
PROBLEM
Fetal movements are not felt after 22 weeks of gestation or during
labour.
GENERAL MANAGEMENT
• Reassure the woman and provide emotional support (page C-7).
• Check the fetal heart rate:
If the fetal heart rate is heard but is depressed and the
mother has had sedatives, wait for the effect of the drugs to
wear off and then recheck;
If the fetal heart cannot be heard, ask several other persons
to listen or use a Doppler stethoscope, if available.
S-132 Loss of fetal movements
DIAGNOSIS
TABLES-19 Diagnosis of loss of fetal movements

Typically Present
• Decreased/absent fetal • Shock Abruptio placentae,
movements • Tense/tender uterus page S-18
• Intermittent or constant • Fetal distress or absent
abdominal pain fetal heart sounds
• Bleeding after 22 weeks
gestation (may be retained in
the uterus)
• Absent fetal movements and • Shock Ruptured uterus,
fetal heart sounds • Abdominal distension! page S-20
• Bleeding (intra-abdominal free fluid
and/or vaginal) • Abnormal uterine contour
• Severe abdominal pain (may • Tender abdomen
decrease after rupture) • Easily palpable fetal parts
• Rapid maternal pulse
• Decreased/absent fetal • Thick meconium-stained Fetal distress, page
movements fluid S-95
• Abnormal fetal heart rate
(less than 100 or more than
180 beats per minute)
• Absent fetal movements and • Symptoms of pregnancy Fetal death, page
fetal heart sounds cease S-132
• Symphysis-fundal height
decreases
• Uterine size decreases
FETAL DEATH
Intrauterine death may be the result of fetal growth restriction, fetal
infection, cord accident or congenital anomalies. Where syphilis is
prevalent, a large proportion of fetal deaths are due to this disease.
If X-ray is available, confirm fetal death after five days. Signs
include overlapping skull bones, hyper-flexed spinal column, gas
bubbles in heart and great vessels and oedema of the scalp.
Alternatively, if ultrasound is available, confirm fetal death.
Signs include absent fetal heart activity, abnormal fetal head shape,
reduced or absent amniotic fluid and doubled-up fetus.
Loss of fetal movements 5-133
Explain the problem to the woman and her family (page C-7).
Discuss with them the options of expectant or active management.
If expectant management is planned:
Await spontaneous onset of labour during the next four weeks;
Reassure the woman that in 90% of cases the fetus is
spontaneously expelled during the waiting period with no
complications.
If platelets are decreasing, four weeks have passed without
spontaneous labour, fibrinogen levels are low or the woman
requests it, consider active management (induction of labour).
If induction of labour is planned, assess the cervix (page P-18):
If the cervix is favourable (soft, thin, partly dilated), induce
labour using oxytocin (page P-18);
cervix using prostaglandins or a Foley catheter (page P-24);
Note: Do not rupture the membranes due to risk of infection.
Deliver by caesarean section only as a last resort.
If spontaneous labour does not occur within four weeks,
platelets are decreasing and the cervix is unfavourable (firm,
thick, closed), or if the woman requests it, ripen the cervix using
misoprostol:
Place misoprostol 25 mcg in the upper vagina. Repeat after six
hours if required;
If there is no response after two doses of 25 mcg, increase to
50 mcg every six hours;
Note: Do not use more than 50 mcg at a time and do not
exceed four doses (200 mcg).
Do not use oxytocin within eight hours of using misoprostol.

Monitor uterine contractions and fetal heart rate of all women
undergoing induction of labour with prostaglandins.
• If there are signs of infection (fever, foul-smelling vaginal

S-134 Loss of fetal movements
If a clotting test shows failure of a clot to form after seven

minutes or a soft clot that breaks down easily, suspect
PRELABOUR RUPTURE OF MEMBRANES S-135
PROBLEM
Watery vaginal discharge after 22 weeks gestation.
GENERAL MANAGEMENT
Confirm accuracy of calculated gestational age, if possible.
Use a high-level disinfected speculum to assess vaginal discharge
(amount, colour, odour) and exclude urinary incontinence.
If the woman complains of bleeding in later pregnancy (after

22 weeks), do not do a digital vaginal examination.
S-136 Prelabour rupture of membranes
DIAGNOSIS
TABLE S-20 Diagnosis of vaginal discharge

Typically Present
• Watery vaginal discharge • Sudden gush or Prelabour rupture
intermittent leaking of fluid of membranes, page
• Fluid seen at introitus S-136
• No contractions within I
hour
• Foul-smelling watery vaginal • History of loss of fluid Amnionitis, page
discharge after 22 weeks • Tender uterus S-139
• Fever/chills • Rapid fetal heart rate
• Abdominal pain • Light• vaginal bleeding
• Foul-smelling vaginal • Itching Vaginitis/cervicitisb
discharge • Frothy/curdish discharge
• No history of loss of fluid • Abdominal pain
• Dysuria
• Bloody vaginal discharge • Abdominal pain Antepartum
• Loss of fetal movements haemorrhage, page
• Heavy, prolonged vaginal S-17
bleeding
• Blood-stained mucus or • Cervical dilatation and Possible term
watery vaginal discharge effacement labour, page C-57
(show) • Contractions or Possible preterm
labour, page S-122
• Light bleeding: takes longer than five minutes for a clean pad or cloth to be
soaked.
b Determine cause and treat accordingly.
MANAGEMENT
PRELABOUR RUPTURE OF MEMBRANES

Prelabour rupture of membranes (PROM) is rupture of the membranes
before labour has begun. PROM can occur either when the fetus is
immature (preterm or before 37 weeks) or when it is mature (term).
CONFIRMING THE DIAGNOSIS

The typical odour of amniotic fluid confirms the diagnosis.
If membrane rupture is not recent or when leakage is gradual,
confirming the diagnosis may be difficult:
Place a vaginal pad over the vulva and examine it (visually and by
odour) one hour later.
Use a high-level disinfected speculum for vaginal examination:
Fluid may be seen coming from the cervix or forming a pool
in the posterior fornix;
Ask the woman to cough; this may cause a gush of fluid.
Do not perform a digital vaginal examination as it does not

help establish the diagnosis and can introduce infection.
If available, perform tests:

The nitrazine test depends upon the fact that vaginal
secretions and urine are acidic while amniotic fluid is alkaline.
Hold a piece of nitrazine paper in a haemostat and touch it
against the fluid pooled on the speculum blade. A change from
yellow to blue indicates alkalinity (presence of amniotic fluid).
Blood and some vaginal infections give false positive results;
For the ferning test, spread some fluid on a slide and let it dry.
Examine it with a microscope. Amniotic fluid crystallizes and
may leave a fern-leaf pattern. False negatives are frequent.
MANAGEMENT
If there is vaginal bleeding with intermittent or constant
abdominal pain, suspect abruptio placentae (page S-18).
discharge), give antibiotics as for amnionitis (page S-139).
If there are no signs of infection and the pregnancy is less than
37 weeks (when fetal lungs are more likely to be immature):
Give antibiotics to reduce maternal and neonatal infective
morbidity and to delay delivery (page C-35):
erythromycin 250 mg by mouth three times per day for

seven days;
PLUS amoxicillin 500 mg by mouth three times per day
for seven days;
Consider transfer to the most appropriate service for care of
the newborn, if possible;
Give corticosteroids to the mother to improve fetal lung
maturity:
betamethasone 12 mg IM, two doses 24 hours apart;
OR dexamethasone 6 mg IM, four doses 12 hours apart.
Note: Corticosteroids should not be used in the presence of
frank infection.
Induce labour using oxytocin (page P-17) at 37 weeks and
give prophylactic antibiotics to help reduce Group B
streptococcus infection in the neonate, even if the woman
received antibiotics previously:
penicillin G 2 million units IV every six hours until
delivery;
OR ampicillin 2 g IV every six hours until delivery;
If there are palpable contractions and blood-stained mucus
discharge, suspect preterm labour (page S-122).
If there are no signs of infection and the pregnancy is 37 weeks
or more:
If the membranes have been ruptured for more than 18
hours, give prophylactic penicillin or ampicillin (page C-35)
to help reduce Group B streptococcus infection in the neonate
(see dosages above). If there are no signs of infection after
delivery, discontinue antibiotics.
Assess the cervix (page P-18):
If the cervix is favourable (soft, thin, partly dilated),
induce labour using oxytocin (page P-17);
If the cervix is unfavourable (firm, thick, closed), ripen
the cervix using prostaglandins and infuse oxytocin (page
P-24) or deliver by caesarean section (page P-43).
AMNIONITIS
• Give a combination of antibiotics until delivery (page C-35):
If the woman delivers vaginally, discontinue antibiotics
postpartum;
If the woman has a caesarean section, continue antibiotics
and give metronidazole 500 mg IV every eight hours until the
woman is fever-free for 48 hours.
Assess the cervix (page P-18):
If the cervix is favourable (soft, thin, partly dilated), induce
cervix using prostaglandins and infuse oxytocin (page P-24)
or deliver by caesarean section (page P-43).
If metritis is suspected (fever, foul-smelling vaginal discharge),
give antibiotics (page S-110).
If newborn sepsis is suspected, arrange for a blood culture and
antibiotics (page S-149).
IMMEDIATE NEWBORN CONDITIONS OR S-141
PROBLEMS
PROBLEMS
The newborn has serious conditions or problems:
gasping or not breathing;
breathing with difficulty (less than 30 or more than 60 breaths
per minute, indrawing of the chest or grunting);
central cyanosis (blueness);
preterm or very low birth weight (less than 32 weeks gestation
or less than 1500 g);
lethargy;
hypothermia (axillary temperature less than 36.5°C);
convulsions.
The newborn has other conditions or problems that require
attention in the delivery room:
low birth weight (1500-2500 g);
possible bacterial infection in an apparently normal newborn
whose mother had prelabour or prolonged rupture of
membranes or amnionitis;
possible congenital syphilis (mother has positive serologic test
or is symptomatic).
Three situations require immediate management: gasping or not
breathing (below), cyanosis (blueness) or breathing with difficulty
(page S-146).
GASPING OR NOT BREATHING
GENERAL MANAGEMENT
Dry the baby, remove the wet cloth and wrap the baby in a dry,
warm cloth.
• Clamp and cut the cord immediately if not already done.
S-142 Immediate newborn conditions or problems
Move the baby to a firm, warm surface under a radiant heater for
resuscitation.
Observe standard infection prevention practices when caring for
and resuscitating a newborn (page C-17).
RESUSCITATION
BOXS-8 Resuscitation equipment
To avoid delays during an emergency situation, it is vital to ensure that

equipment is in good condition before resuscitation is needed:
o Have the appropriate size masks available according to the expected
size of the baby (size 1 for a normal weight newborn and size 0 for a
small newborn).
o Block the mask by making a tight seal with the palm of your hand and
squeeze the bag:
If you feel pressure against your hand, the bag is generating
adequate pressure;
- If the bag reinflates when you release the grip, the bag is functioning
properly.
OPENING THE AIRWAY

Position the newborn (Fig S-28):
Place the baby on its back;
Position the head in a slightly extended position to open the
airway;
Keep the baby wrapped or covered, except for the face and
upper chest.
FIGURES-28 Correct position of the head for ventilation; note

that the neck is less extended than in adults
Clear the airway by suctioning first the mouth and then the nostrils.
If blood or meconium is in the baby's mouth or nose, suction
immediately to prevent aspiration.
Note: Do not suction deep in the throat as this may cause the
baby's heart to slow or the baby may stop breathing.
Reassess the baby:
If the newborn starts crying or breathing, no further
immediate action is needed. Proceed with initial care of the
newborn (page C-75);
If the baby is still not breathing, start ventilating (see below).
VENTILATING THE NEWBORN
Recheck the newborn's position. The neck should be slightly
extended (Fig S-28, page S-142).
Position the mask and check the seal (Fig S-29):
Place the mask on the newborn's face. It should cover the
chin, mouth and nose;
Form a seal between the mask and the face;
Squeeze the bag with two fingers only or with the whole hand,
depending on the size of the bag;
Check the seal by ventilating twice and observing the rise of
the chest.
FIGURE S-29 Ventilation with bag and mask
Once a seal is ensured and chest movement is present, ventilate the

newborn. Maintain the correct rate (approximately 40 breaths per
minute) and pressure (observe the chest for an easy rise and fall):
If the baby's chest is rising, ventilation pressure is probably
adequate;
If the baby's chest is not rising:
Repeat suction of mouth and nose to remove mucus,
blood or meconium from the airway;
Recheck and correct, if necessary, the position of the
newborn (Fig S-28, page S-142);
Reposition the mask on the baby's face to improve the
seal between mask and face;
Squeeze the bag harder to increase ventilation pressure.
If the mother of the newborn received pethidine or morphine
prior to delivery, consider administering naloxone after vital signs
have been established (Box S-9, page S-145).
• Ventilate for 1 minute and then stop and quickly assess if the
newborn is breathing spontaneously:
If breathing is normal (30-60 breaths per minute) and there
is no indrawing of the chest and no grunting for 1 minute,
no further resuscitation is needed. Proceed with initial care of
the newborn (page C-76);
If the newborn is not breathing, or the breathing is weak,
continue ventilating until spontaneous breathing begins.
If the newborn starts crying, stop ventilating and continue
observing breathing for 5 minutes after crying stops:
If breathing is normal (30-60 breaths per minute) and there
is no indrawing of the chest and no grunting for 1 minute,
no further resuscitation is needed. Proceed with initial care of
the newborn (page C-76);
If the respiratory rate is less than 30 breaths per minute,
continue ventilating;
If there is severe indrawing of the chest, ventilate with
oxygen, if available (Box S-10, page S-147). Arrange to
transfer the baby to the most appropriate service for the care of
sick newborns.
If the newborn is not breathing regularly after 20 minutes of

ventilation:
Transfer the baby to the most appropriate service for the care
of sick newborns;
During the transfer, keep the newborn warm and ventilated, if
necessary.
If there is no gasping or breathing at all after 20 minutes of
ventilation, stop ventilating; the baby is stillborn. Provide
emotional support to the family (page C-7).
BOXS-9 Counteracting respiratory depression in the newborn
caused by narcotic drugs
If the mother received pethidine or morphine, naloxone is the drug to

counteract respiratory depression in the newborn caused by these drugs.
Note: Do not administer naloxone to newborns whose mothers are
suspected of having recently abused narcotic drugs.
• If there are signs of respiratory depression, begin resuscitation
immediately:
- After vital signs have been established, give naloxone 0.1 mglkg
body weight IV to the newborn;
- Naloxone may be givet'IM after successful resuscitation if the
infant has adequate peripheral circulation. Repeated doses may be
required to prevent recurrent respiratory depression.
• If there are no signs of respiratory depression, but pethidine or
morphine was given within 4 hours of delivery, observe the baby
expectantly for signs of respiratory depression and treat as above if
they occur.
CARE AFTER SUCCESSFUL RESUSCITATION

Prevent heat loss:
Place the baby skin-to-skin on the mother's chest and cover
the baby's body and head;
Alternatively, place the baby under a radiant heater.
• Examine the newborn and count the number of breaths per minute:
If the baby is cyanotic (bluish) or is having difficulty
breathing (less than 30 or more than 60 breaths per minute,
indrawing of the chest or grunting), give oxygen by nasal

catheter or prongs (below).
Measure the baby's axillary temperature:
If the temperature is 36.5°C or more, keep the baby skin-to-
skin on the mother's chest and encourage breastfeeding;
If the temperature is less than 36.5°C, rewarm the baby
(page S-148).
Encourage the mother to begin breastfeeding. A newborn that
required resuscitation is at higher risk of developing
hypoglycaemia:
If suckling is good, the newborn is recovering well;
If suckling is not good, transfer the baby to the appropriate
service for the care of sick newborns.
Ensure frequent monitoring of the newborn during the next 24
hours. If signs of breathing difficulties recur, arrange to transfer
the baby to the most appropriate service for the care of sick
newborns.
CYANOSIS OR BREATHING DIFFICULTY

If the baby is cyanotic (bluish) ~ having difficulty breathing
(less than 30 or more than 60 breaths per minute, indrawing of the
chest or grunting) give oxygen:
Suction the mouth and nose to ensure the airways are clear;
Give oxygen at 0.5 L per minute by nasal catheter or nasal
prongs (Box S-10, page S-147);
Transfer the baby to the appropriate service for the care of sick
newborns.
Ensure that the baby is kept warm. Wrap the baby in a soft, dry
cloth, cover with a blanket and ensure the head is covered to
prevent heat loss.
BOXS-10 Use of oxygen
When using oxygen, remember:

o Only use supplemental oxygen for difficulty in breathing or cyanosis;
o If the baby is having severe indrawing of the chest, is gasping for
breath or is persistently cyanotic, increase the concentration of
oxygen by nasal catheter, nasal prongs or oxygen hood.
Note: Indiscriminate use of supplemental oxygen for premature infants has
been associated with the risk of blindness.
ASSESSMENT
Many serious conditions in newboms-bacterial infections,
malformations, severe asphyxia and hyaline membrane disease due to
preterm birth-present in a similar way with difficulty in breathing,
lethargy and poor or no feeding.
It is difficult to distinguish between the conditions without diagnostic
methods. Nevertheless, treatment must start immediately even without
a clear diagnosis of a specific cause. Babies with any of these problems
should be suspected to have a serious condition and should be
transferred without delay to the appropriate service for the care of sick
newboms.
MANAGEMENT
VERY LOW BIRTH WEIGHT OR VERY PRETERM BABY

If the baby is very small (less than 1500 g or less than 32 weeks),
severe health problems are likely and include difficulty in breathing,
inability to feed, severe jaundice and infection. The baby is susceptible
to hypothermia without special thermal protection (e.g. incubator).
Very small newboms require special care. They should be transferred to
the appropriate service for caring for sick and small babies as early as
possible. Before and during transfer:
prevent heat loss.
If maternal history indicates possible bacterial infection, give

first dose of antibiotics:
gentamicin 4 mg/kg body weight IM (or give kanamycin);
PLUS ampicillin 100 mg/kg body weight IM (or give benzyl
penicillin).
If the baby is cyanotic (bluish) or is having difficulty breathing
(less than 30 or more than 60 breaths per minute, indrawing of the
chest or grunting), give oxygen by nasal catheter or prongs (page
S-146).
LETHARGY
If the baby is lethargic (low muscular tone, does not move), it is very
likely that the baby has a severe illness and should be transferred to the
appropriate service for the care of sick of newboms.
HYPOTHERMIA
Hypothermia can occur quickly in a very small baby or a baby who was
resuscitated or separated from the mother. In these cases, temperature
may quickly drop below 35°C. Rewarm the baby as soon as possible:
If the baby is very sick or is very hypothermic (axillary
temperature less than 35°C):
Use available methods to begin warming the baby (incubator,
radiant heater, warm room, heated bed);
Transfer the baby as quickly as possible to the appropriate
service for the care of preterm or sick newboms;
If the baby is cyanotic (bluish) or is having difficulty
breathing (less than 30 or more than 60 breaths per minute,
indrawing of the chest or grunting), give oxygen by nasal
catheter or prongs (page S-146).
If the baby is not very sick and axillary temperature is 35°C or
more:
Ensure that the baby is kept warm. Wrap the baby in a soft,
dry cloth, cover with a blanket and ensure the head is covered
to prevent heat loss;
Encourage the mother to begin breastfeeding as soon as the
baby is ready;
Monitor axillary temperature hourly until normal;

Alternatively, the baby can be placed in an incubator or under
a radiant heater.
CONVULSIONS
Convulsions in the first hour of life are rare. They could be caused by
meningitis, encephalopathy or severe hypoglycaemia.
prevent heat loss.
Transfer the baby to the appropriate service for the care of sick
newborns as quickly as possible.
MODERATELY PRETERM OR LOW BIRTH WEIGHT BABY

Moderately preterm (33-37 weeks) or low birth weight (1500--2500 g)
babies may start to develop problems soon after birth.
If the baby has no breathing difficulty and remains adequately
warm while in skin-to-skin contact with the mother:
Keep the baby with the mother;
Encourage the mother to initiate breastfeeding within the first
hour if possible.
If the baby is cyanotic (bluish) or is having difficulty breathing
(less than 30 or more than 60 per minute, indrawing of the chest or
grunting), give oxygen by nasal catheter or prongs (page S-146).
• If axillary temperature drops below 35°C, rewarrn the baby
(page S-148).
PRETERM AND/OR PROLONGED RUPTURE OF

MEMBRANES AND AN ASYMPTOMATIC NEWBORN
The following are suggested guidelines which may be modified
according to local situations:
If the mother has clinical signs of bacterial infection or if
membranes were ruptured for more than 18 hours before
delivery even if the mother has no clinical signs of infection:
S·150 Immediate newborn conditions or problems
Keep the baby with the mother and encourage her to continue
breastfeeding;
Make arrangements with the appropriate service that cares for
sick newborns to take a blood culture and start the newborn on
antibiotics.
If these conditions are not met, do not treat with antibiotics.
Observe the baby for signs of infection for three days:
Keep the baby with the mother and encourage her to continue
breastfeeding;
If signs of infection occur within 3 days, make arrangements
with the appropriate service that cares for sick newborns to
take a blood culture and start the newborn on antibiotics.
CONGENITAL SYPHILIS
If the newborn shows signs of syphilis, transfer the baby to the
appropriate service for the care of sick newborns. Signs of syphilis
include:
generalized oedema;
skin rash;
blisters on palms or soles;
rhinitis;
anal condylomata;
enlarged liver/spleen;
paralysis of one limb;
jaundice;
pallor;
spirochetes seen on darkfield examination of lesion, body fluid
or cerebrospinal fluid.
If the mother has a positive serologic test for syphilis or is
symptomatic but the newborn shows no signs of syphilis,
whether or not the mother was treated, give benzathine penicillin
50 000 units/kg body weight IM as a single dose.
SECTION 3
PROCEDURES
PARACERVICAL BLOCK P-1
TABLE P-1 Indications and precautions for paracervical block
Indications Precautions
• Dilatation and curettage • Make sure there are no known

• Manual vacuum aspiration allergies to lignocaine or related
drugs
• Do not inject into a vessel
• Maternal complications are rare but
may include haematoma
Review general care principles (page C-17).

• Prepare 20 mL 0.5% lignocaine solution without adrenaline (page
C-39).
Use a 3.5-cm, 22-gauge or 25-gauge needle to inject the lignocaine
solution.
• If using a tenaculum to grasp the cervix, first inject 1 mL of
0.5% lignocaine solution into the anterior or posterior lip of the
cervix which has been exposed by the speculum.
Note: With incomplete abortion, a ring (sponge) forceps is
preferable, as it is less likely than the tenaculum to tear the cervix
with traction and does not require the use of lignocaine for
placement.
With the tenaculum or ring forceps on the cervix vertically (one
tooth in the external os, the other on the face of the cervix), use
slight traction and movement to help identify the area between the
smooth cervical epithelium and the vaginal tissue. This is the site
for insertion of the needle around the cervix.
Insert the needle just under the epithelium.
Tip: Some practitioners have suggested the following step to divert
the woman's attention from the insertion of the needle: Place the
tip of the needle just over the site selected for insertion and ask the
woman to cough. This will "pop" the needle just under the surface
of the tissue.
Note: Aspirate (pull back on the plunger) to be sure that no vessel
has been penetrated. If blood is returned in the syringe with
aspiration, remove the needle. Recheck the position carefully and .
try again. Never inject if blood is aspirated. The woman can
suffer convulsions and death if IV injection of lignocaine
occurs.
P-2 Paracervical block
Inject 2 mL of lignocaine solution just under the epithelium, not

deeper than 3 mm, at 3, 5, 7 and 9 o'clock (Fig P-1). Optional
injection sites are at 2 and 10 o'clock. When correctly placed, a
swelling and blanching of the tissue can be noted.
At the conclusion of the set of injections, wait two minutes and
then pinch the cervix with forceps. If the woman can feel the
pinch, wait two more minutes and then retest.
Anaesthetize early to provide sufficient time for effect.
FIGUREP-1 Paracervical block injection sites
Optional
njection sites
,.._:\\M~~Injection sites
PUDENDAL BLOCK P-3
TABLEP-2 Indications and precautions for pudendal block
• Instrumental or breech delivery • Make sure there are no known

• Episiotomy and repair of perineal allergies to lignocaine or related
tears drugs
• Craniotomy or craniocentesis • Do not inject into a vessel

Prepare 40 rnL 0.5% lignocaine solution without adrenaline (page
C-39).
Note: It is best to limit the pudendal block to 30 rnL of solution so
that a maximum of 10 rnL of additional solution may be injected
into the perineum during repair of tears, if needed.
Use a 15-cm, 22-gauge needle to inject the lignocaine.
The target is the pudendal nerve as it passes through the lesser sciatic
notch. There are two approaches:
through the perineum;
through the vagina.
The perineal approach requires no special instrument. For the vaginal
approach, a special needle guide ("trumpet"), if available, provides
protection for the provider's fingers.
PERINEAL APPROACH
• Infiltrate the perineal skin on both sides of the vagina using 10 rnL
of lignocaine solution.
aspiration, remove the needle. Recheck the position carefully and
occurs.
• Wearing high-level disinfected or sterile gloves, place two fingers
in the vagina and guide the needle through the perineal tissue to the
tip of the woman's left ischial spine (Fig P-2, page P-4).
P-4 Pudendal block
FIGUREP-2 Perineal approach
~I
Inject 10 mL of lignocaine solution in the angle between the ischial

spine and the ischial tuberosity.
Pass the needle through the sacrospinous ligament and inject
another 10 mL of lignocaine solution.
Repeat the procedure on the opposite side.
If an episiotomy is to be performed, infiltrate the episiotomy site
in the usual manner at this time (page P-71).
At the conclusion of the set of. injections, wait two minutes and
then pinch the area with forceps. If the woman can feel the pinch,
wait two more minutes and then retest.

Pudendal block P-5
VAGINAL APPROACH
Wearing high-level disinfected or sterile gloves, use the left index
finger to palpate the woman's left ischial spine through the vaginal
wall (Fig P-3).
FIGURE P-3 Vaginal approach without a needle guide
• Use the right hand to advance the needle guide ("trumpet") towards
the left spine, keeping the left fingertip at the end of the needle
guide.
• Place the needle guide just below the tip of the ischial spine.
Remember to keep the fingertip near the end of the needle

guide. Do not place the fingertip beyond the end of the needle
guide as needle-stick injury can easily occur.
Advance a 15-cm, 22-gauge needle with attached syringe through

the guide.
• Penetrate the vaginal mucosa until the needle pierces the
sacrospinous ligament.
P-6 Pudendal block

occurs.
Inject 10 mL of lignocaine solution.
Withdraw the needle into the guide and reposition the guide to just
above the ischial spine.
Penetrate the vaginal mucosa and aspirate again to be sure that no
vessel has been penetrated.
Inject another 5 mL of lignocaine solution.
Repeat the procedure on the other side, using the right index finger
to palpate the woman's right ischial spine. Use the left hand to
advance the needle and needle guide and inject the lignocaine
solution.
If an episiotomy is to be performed, infiltrate the episiotomy site
in the usual manner at this time (page P-71).
then pinch the area with forceps. If the woman can feel the pinch,

LOCAL ANAESTHESIA FOR CAESAREAN P-7
SECTION
Local anaesthesia is a safe alternative to general, ketamine or spinal
anaesthesia when these anaesthetics or persons trained in their use are
not available.
The use of local anaesthesia for caesarean section requires that the
provider counsel the woman and reassure her throughout the procedure.
The provider must keep in mind that the woman is awake and alert, and
should use instruments and handle tissue as gently as possible.
TABLEP-3 Indications and precautions for local anaesthesia for
caesarean section
• Caesarean section (especially in • Avoid use in women with

women with heart failure) eclampsia, severe pre-eclampsia or
previous laparotomy
• Avoid use in women who are
obese, apprehensive or allergic to
lignocaine or related drugs
• Avoid use if little experience at
caesarean section
• Do not inject into a vessel
• Review general care principles (page C-17) and start an IV

infusion (page C-21).
Prepare 200 mL of 0.5% lignocaine solution with 1:200 000
adrenaline (page C-39). Usually less than half this volume
(approximately 80 mL) is needed in the first hour.
• If the fetus is alive, give pethidine 1 mg/kg body weight (but not
more than 100 mg) IV slowly (or give morphine 0.1 mg/kg body
weight IM) and promethazine 25 mg IV after delivery.
Alternatively, pethidine and promethazine may be given before
delivery, but the baby may need to be given naloxone 0.1 mg/kg
body weight IV at birth.
If the fetus is dead, give pethidine 1 mglkg body weight (but not
more than 100 mg) IV slowly (or give morphine 0.1 mg/kg body
weight IM) and promethazine 25 mg IV.
Talk to the woman and reassure her throughout the procedure.

P-8 Local anaesthesia for caesarean section
Using a 10-cm needle, infiltrate one band of skin and subcutaneous

tissue on either side of the proposed incision, two finger breadths
apart (Fig P-4).
occurs.
FIGUREP-4 Infiltration of skin and subcutaneous tissue with
local anaesthesia for caesarean section
Umbilicus
Raise a long wheal of lignocaine solution 3-4 cm on either side of

the midline from the symphysis pubis to a point 5 cm above the
umbilicus.
Infiltrate the lignocaine solution down through the layers of the
abdominal wall. The needle should remain almost parallel to the
skin. Take care not to pierce the peritoneum and insert the needle
into the uterus, as the abdominal wall is very thin at term.
then pinch the incision site with forceps. If the woman can feel the
Note: If the caesarian section is performed under local

anaesthesia, make a midline incision that is about 4 cm longer than
when general anaesthesia is used. A Pfannenstiel incision should
Local anaesthesia for caesarean section P-9
not be used as it takes longer, retraction is poorer and it requires

more local anaesthetic.
The anaesthetic effect can be expected to last about 60

minutes.
Proceed with caesarean section (page P-43) keeping the following in

mind:
Do not use abdominal packs. Use retractors as little as possible and
with a minimum of force.
Inject 30 mL of lignocaine solution beneath the uterovesical
peritoneum as far laterally as the round ligaments. No additional
anaesthetic is required. The peritoneum is sensitive to pain; the
myometrium is not.
Inform the woman that she will feel some discomfort from traction
when the baby is delivered. This is usually no more than occurs
during vaginal delivery.
Repair the uterus without removing it from the abdomen.
Additional local anaesthesia may be necessary to repair the
abdominal wall.
P-10 Local anaesthesia for caesarean section
SPINAL (SUBARACHNOID) ANAESTHESIA P-11
TABLEP-4 Indications and precautions for spinal anaesthesia
• Caesarean section • Make sure there are no known allergies to

• Laparotomy lignocaine or related drugs
• Repair of third and fourth • Avoid use in women with uncorrected
degree perineal tears hypovolaemia, severe anaemia, coagulation
disorders, haemorrhage, local infection,
severe pre-eclampsia, eclampsia or heart
failure due to heart disease

Infuse 500-1000 mL of IV fluids (normal saline or Ringer's
lactate) to pre-load the woman and avoid hypotension. This should
be done 30 minutes before anaesthesia.
• Prepare 1.5 mL of the local anaesthetic: 5% lignocaine in 5%
dextrose. Add 0.25 mL of adrenaline (1: 1000) if the anaesthetic
needs to be effective for longer than 45 minutes.
Ask the woman to lie on her side (or sit up), ensuring that the
lumbar spine is well flexed. Ask the woman to flex her head onto
her chest and round her back as much as possible.
Identify and, if required, mark the proposed site of injection. A
vertical line from the iliac crest upward will cross the woman's
vertebral column between the spines of the fourth and fifth lumbar
vertebrae. Choose this space or the space just above it.
Sterility is critical. Do not touch the point or shaft of the spinal

needle with your hand. Hold the needle only by its hub.
• Inject 1% lignocaine solution using a fine needle to anaesthetize

the woman's skin.
Introduce the finest spinal needle available (22- or 23-gauge) in the
midline through the wheal, at a right angle to the skin in the
vertical plane.
Note: Fine needles tend to bend.
If the needle hits bone, it may not be in the midline. Withdraw the
needle and reinsert it, directing it slightly upwards while aiming for
the woman's umbilicus.
P-12 Spinal anaesthesia
Advance the spinal needle towards the subarachnoid space. A

distinct loss of resistance will be felt as the needle pierces the
ligamentum flavum.
Once the needle is through the ligamentum flavum, push the needle
slowly through the dura. There will be another slight loss of
resistance as the dura is pierced.
• Remove the stylet. Cerebrospinal fluid should flow out the needle.
• If cerebrospinal fluid does not come out, reinsert the stylet and
rotate the needle gently. Remove the stylet to see ifthe fluid is
flowing out. If you fail two times, try another space.
Inject 1-1.25 mL of the local anaesthetic solution. For pregnant
women who have not delivered, a smaller dose of the drug is
needed since the available subarachnoid space is reduced due to
engorged epidural veins.
Help the woman to lie on her back. Have the operating table tilted
to the left or place a pillow or folded linen under her right lower
back to decrease supine hypotension syndrome.
Recheck the woman's blood pressure. A fall in blood pressure is
likely. If there is significant hypotension, give the woman more
IV fluids (500 mL quickly):
If this does not raise her blood pressure, give ephedrine 0.2
mglkg body weight IV in 3 mg increments;
If blood pressure continues to fall after giving IV
ephedrine boluses four times, give ephedrine 30 mg IM.
After injecting the local anaesthetic solution, wait two minutes and
then pinch the incision site with forceps. If the woman can feel the
pinch, wait two minutes and then retest.
After surgery, keep the woman flat for at least six hours with only
a single pillow beneath her head to prevent post-spinal headache.
She must not sit up or strain during this period.
KETAMINE P-13
TABLE P-S Indications and precautions for ketamine anaesthesia
• Any procedure that is relatively • When used alone, ketamine can

short (less than 60 minutes) and cause unpleasant hallucinations.
where muscle relaxation is not Avoid use in women with a history
required (e.g. repair of perineal tears of psychosis. To prevent
or extensive cervical tears, manual hallucinations, give diazepam 10 mg
removal of placenta, caesarean IV after the baby is delivered
section, drainage of breast abscess) • By itself ketamine does not provide
• Suitable as a back-up if inhalation muscular relaxation, so the incision
apparatus (or gas supply for a for caesarean section may need to be
Boyle's anaesthesia machine) fails longer
or if general anaesthesia is used • Ketamine should not be used in
without an inhalation apparatus women with elevated blood
pressure, pre-eclampsia, eclampsia
or heart disease
Review general care principles (page C-17) and start an IV

• Ketamine may be given IM, IV or by infusion. The dose of
ketamine is variable:
Most women will require 6-10 mg/kg body weight IM.
Surgical anaesthesia is reached within 10 minutes and lasts up
to 30 minutes;
Alternatively, give 2 mg/kg body weight IV slowly over two
minutes (in which case the action lasts for only 15 minutes);
Infusion of ketamine is described below. This is suitable for
caesarean section;
When additional pain relief is needed, give ketamine 1 mg/kg
body weight IV.
Ketamine anaesthesia should not be used in women with

elevated blood pressure, pre-eclampsia, eclampsia or heart
disease.
P-14 Ketamine
KETAMINE INFUSION
PREMEDICATION
Give atropine sulfate 0.6 mg IM 30 minutes prior to surgery.
Give diazepam 10 mg IV at the time of induction to prevent
hallucinations (for caesarean section, give diazepam after the baby
is delivered).
INDUCTION AND MAINTENANCE

Check the woman's vital signs (pulse, blood pressure, respiration,
temperature).
Insert a mouth gag to prevent airway obstruction by the tongue.
Induction of anaesthesia is achieved by administering ketamine
two mg/kg body weight IV slowly over 2 minutes. For short
procedures lasting less than 15 minutes, this will provide adequate
anaesthesia.
For longer procedures, infuse ketamine 200 mg in 1 L dextrose at 2
mg per minute (i.e. 20 drops per minute).
Check the level of anaesthesia before proceeding with the surgery.
Pinch the incision site with forceps. If the woman can feel the
pinch, wait two minutes and then retest.
Monitor vital signs (pulse, blood pressure, respiration, temperature)
every 10 minutes during the procedure.
POST-PROCEDURE CARE
Discontinue ketamine infusion and administer a postoperative
analgesic suited to the type of surgery performed (page C-46).
• Maintain observations every 30 minutes until the woman is fully
awake; ketamine anaesthesia may take up to 60 minutes to wear
off.
EXTERNAL VERSION P-15
Review for indications. Do not perform this procedure before 37
weeks or if facilities for emergency caesarian section are not
available.
Have the woman lie on her back, and elevate the foot of the bed.
Listen to and note the fetal heart rate. If there are fetal heart rate
abnormalities (less than 100 or more than 180 beats per minute):
Do not proceed with external version;
Manage as for fetal distress (page S-95).
• Palpate the abdomen to confirm the presentation and position of
the fetal head, back and hips.
• To mobilize the breech, gently lift the lowest part of the fetus from
the pelvic inlet by grasping above the pubic bone (Fig P-5 A, page
P-16).
Bring the head and buttocks of the fetus closer to each other to
achieve forward rotation. Rotate the fetus slowly by guiding the
head in a forward roll as the buttocks are lifted (Fig P-5 B-C, page
P-16).
Listen to the fetal heart rate after every attempt at external version.
If an abnormal fetal heart rate is detected:
Manage as for fetal distress (page S-95);
Reassess every 15 minutes;
If the fetal heart rate does not stabilize within the next 30
minutes, deliver by caesarean section (page P-43).
• If the procedure is successful, have the woman remain lying down
for 15 minutes. Counsel her to return if bleeding or pain occurs or
if she believes the baby has returned to the previous presentation.
If the procedure is unsuccessful, try again using a backward roll
(Fig P-5 D).
• If the procedure is still unsuccessful and the fetal heart rate is
good, tocolytics may increase the chances of successful version.
Give:
terbutaline 250 mcg IV slowly over five minutes;
OR salbutamol 0.5 mg IV slowly over five minutes.
P-16 External version
If the procedure is still unsuccessful, attempt version again after

one week or if the woman presents in early labour with breech or
transverse lie.
FIGUREP-5 External version of a breech presentation.
A. Mobilization B. Manual forward C. Completion of

of the breech rotation using both forward roll
hands, one to push the
breech and the other
to guide the vertex
D. Backward roll
INDUCTION AND AUGMENTATION OF LABOUR P-17
Induction of labour and augmentation of labour are performed for

different indications but the methods are the same.
• Induction of labour: stimulating the uterus to begin labour.
Augmentation of labour: stimulating the uterus during labour to
increase the frequency, duration and strength of contractions.
A good labour pattern is established when there are three contractions
in 10 minutes, each lasting more than 40 seconds.
If the membranes are intact, it is recommended practise in both
induction and augmentation of labour to first perform artificial rupture
of membranes (ARM). In some cases, this is all that is needed to induce
labour. Membrane rupture, whether spontaneous or artificial, often sets
off the following chain of events:
Amniotic fluid is expelled;
Uterine volume is decreased;
Prostaglandins are produced, stimulating labour;
Uterine contractions begin (if the woman is not in labour) or
become stronger (if she is already in labour).
ARTIFICIAL RUPTURE OF MEMBRANES

Review for indications.
Note: In areas where HIV and/or hepatitis are highly prevalent, it is
prudent to leave the membranes intact for as long as possible to
reduce perinatal transmission of HIV.
Listen to and note the fetal heart rate.
Ask the woman to lie on her back with her legs bent, feet together
and knees apart.
Wearing high-level disinfected or sterile gloves, use one hand to
examine the cervix and note the consistency, position, effacement
and dilatation.
Use the other hand to insert an amniotic hook or a Kocher clamp
into the vagina.
Guide the clamp or hook towards the membranes along the fingers
in the vagina.
P-18 Induction and augmentation of labour
• Place two fingers against the membranes and gently rupture the
membranes with the instrument in the other hand. Allow the
amniotic fluid to drain slowly around the fingers.
Note the colour of the fluid (clear, greenish, bloody). If thick
meconium is present, suspect fetal distress (page S-95).
• After ARM, listen to the fetal heart rate during and after a
contraction. If the fetal heart rate is abnormal (less than 100 or
more than 180 beats per minute), suspect fetal distress (page
S-95).
• If membranes have been ruptured for 18 hours, give
prophylactic antibiotics to help reduce Group B streptococcus
infection in the neonate (page C-35):
penicillin G 2 million units IV;
OR ampicillin 2 g IV, every six hours until delivery;
If there are no signs of infection after delivery, discontinue
antibiotics.
• If good labour is not established one hour after ARM, begin
oxytocin infusion (page P-19).
If labour is induced because of severe maternal disease (e.g.
sepsis or eclampsia), begin oxytocin infusion at the same time as
ARM.
INDUCTION OF LABOUR
ASSESSMENT OF THE CERVIX

The success of induction of labour is related to the condition of the
cervix at the start of induction. To assess the condition of the cervix, a
cervical exam is performed and a score is assigned based on the criteria
in Table P-6:
• If the cervix is favourable (has a score of 6 or more), labour is
usually successfully induced with oxytocin alone.
• If the cervix is unfavourable (has a score of 5 or less), ripen the
cervix using prostaglandins (page P-24) or a Foley catheter (page
P-25) before induction.
TABLEP-6 Assessment of cervix for induction of labour
Rating
Factor 0 2 3
Dilatation (cm) closed 1-2 3-4 more than 5
Length of cervix (cm) more than 4 3-4 1-2 less than 1
Consistency Firm Average Soft
Position Posterior Mid Anterior
Descent by station of -3 -2 -1,0 +1, +2

head (cm from ischial
spines)
Descent by abdominal 4/5 3/5 2/5 1/5

palpation (fifths of
head palpable)
OXYTOCIN
Use oxytocin with great caution, as fetal distress can occur from
hyperstimulation and, rarely, uterine rupture can occur. Multiparous
women are at higher risk for uterine rupture.
Carefully observe women receiving oxytocin.
The effective dose of oxytocin varies greatly between women.

Cautiously administer oxytocin in IV fluids (dextrose or normal saline),
gradually increasing the rate of infusion until good labour is established
(three contractions in 10 minutes, each lasting more than 40 seconds).
Maintain this rate until delivery. The uterus should relax between
contractions.
When oxytocin infusion results in a good labour pattern,

maintain the same rate until delivery.
Monitor the woman's pulse, blood pressure and contractions, and

check the fetal heart rate.
Be sure induction is indicated, as failed induction is usually

followed by caesarean section.
Ensure that the woman is on her left side.

• Record the following on a partograph every 30 minutes (page
C-65):
rate of infusion of oxytocin (see below);
Note: Changes in arm position may alter the flow rate;
duration and frequency of contractions;
fetal heart rate. Listen every 30 minutes, always immediately
after a contraction. If the fetal heart rate is less than 100
beats per minute, stop the infusion and manage for fetal
distress (page S-95).
Women receiving oxytocin should never be left alone.
Infuse oxytocin 2.5 units in 500 mL of dextrose (or normal saline)

at 10 drops per minute (Table P-7, page P-22 and Table P-8, page
P-23). This is approximately 2.5 miU per minute.
Increase the infusion rate by 10 drops per minute every 30 minutes
until a good contraction pattern is established (three contractions in
10 minutes, each lasting more than 40 seconds).
Maintain this rate until delivery is completed.
If hyperstimulation occurs (any contraction lasts longer than 60
seconds) or if there are more than four contractions in 10
minutes, stop the infusion and relax the uterus using tocolytics:
terbutaline 250 mcg IV slowly over five minutes;
OR salbutamol10 mg in 1 L IV fluids (normal saline or
Ringer's lactate) at 10 drops per minute.
• If a good contraction pattern has not been established with the
infusion rate at 60 drops per minute:
Increase the oxytocin concentration to 5 units in 500 mL of
dextrose (or normal saline) and adjust the infusion rate to 30
drops per minute (15 miU per minute);
Induction and augmentation of labour P·21
Increase the infusion rate by 10 drops per minute every 30

minutes until a good contraction pattern is established or the
maximum rate of 60 drops per minute is reached.
If a good contraction pattern still has not been established using
the higher concentration of oxytocin:
In multigravida and in women with previous caesarean
scars, induction has failed; deliver by caesarean section (page
P-43);
Do not use oxytocin 10 units in 500 mL (i.e. 20 miU/mL) in

multigravida and women with previous caesarean section.
In primigravida:
Infuse oxytocin at the higher concentration (10 units in
500 mL) according to the protocol in Table P-8;
If good contractions are not established at the
maximum dose, deliver by caesarean section (page
P-43).
TABLEP-7 Oxytocin infusion rates for induction of labour

(Note 1 mL 20 drops)
Time Since Oxytocin Drops Approximate Volume Total

Induction Concentration per Dose (miU/ Infused Volume
(hours) Minute minute) Infused
0.00 2.5 units in 500 10 3 0 0
mL dextrose or
normal saline
(5 miU/mL)
0.50 Same 20 5 15 15
1.00 Same 30 8 30 45
1.50 Same 40 10 45 90
2.00 Same 50 13 60 150
2.50 Same 60 15 75 225
3.00 5 units in 500 30 15 90 315
mL dextrose or
normal saline
(10 rnlU/mL)
3.50 Same 40 20 45 360
4.00 Same 50 25 60 420
4.50 Same 60 30 75 495
5.00 10 units in 500 30 30 90 585
mL dextrose or
normal saline
(20miU/mL)
5.50 Same 40 40 45 630
6.00 Same 50 50 60 690
6.50 Same 60 60 75 765
7.00 Same 60 60 90 855
Increase the rate of oxytocin infusion only to the point where

a good contraction pattern is established and then maintain
the infusion at that rate.
Induction and augmentation of labour P·23
TABLEP-8 Rapid escalation for primigravida only: Oxytocin

infusion rates for induction oflabour (Note 1 mL 20
drops)
Time Since Oxytocin Drops Approximate Volume Total
Induction Concentration per Dose (miU/ Infused Volume
(hours) Minute minute) Infused
0.00 2.5 units in 500 15 4 0 0
mL dextrose or
normal saline
(5 miU/mL)
0.50 Same 30 8 23 23
1.00 Same 45 11 45 68
1.50 Same 60 15 68 135
2.00 5 units in 500 30 15 90 225
mL dextrose or
normal saline
(lOmiU/mL)
2.50 Same 45 23 45 270
3.00 Same 60 30 68 338
3.50 10 units in 500 30 30 90 428
mL dextrose or
normal saline
(20 mlU/mL)
4.00 Same 45 45 45 473
4.50 Same 60 60 68 540
5.00 Same 60 60 90 630
PROSTAGLANDINS
Prostaglandins are highly effective in ripening the cervix during
induction of labour.
• Monitor the woman's pulse, blood pressure and contractions, and
check the fetal heart rate. Record findings on a partograph (page
C-65).
Prostaglandin E2 (PGE2) is available in several forms (3 mg
pessary or 2-3 mg gel). The prostaglandin is placed high in the
posterior fornix of the vagina and may be repeated after six hours if
required.
Monitor uterine contractions and fetal heart rate of all women

undergoing induction of labour with prostaglandins.
Discontinue use of prostaglandins and begin oxytocin infusion if:

membranes rupture;
cervical ripening has been achieved;
good labour has been established;
OR 12 hours have passed.
MISOPROSTOL
Use misoprostol to ripen the cervix only in highly selected
situations such as:
severe pre-eclampsia or eclampsia when the cervix is
unfavourable and safe caesarean section is not immediately
available or the baby is too premature to survive;
fetal death in-utero if the woman has not gone into
spontaneous labour after four weeks and platelets are
decreasing.
• Place misoprostol 25 mcg in the posterior fornix of the vagina.
Repeat after six hours, if required;
If there is no response after two doses of 25 mcg, increase to 50
mcg every six hours;
Do not use more than 50 mcg at a time and do not exceed four
doses (200 mcg).
Do not use oxytocin within 8 hours of using misoprostol.

Monitor uterine contractions and fetal heart rate.
FOLEY CATHETER
The Foley catheter is an effective alternative to prostaglandins for
cervical ripening and labour induction. It should, however, be avoided
in women with obvious cervicitis or vaginitis.
If there is a history of bleeding or ruptured membranes or

obvious vaginal infection, do not use a Foley catheter.

• Gently insert a high-level disinfected or sterile speculum into the
vagina.
• Hold the catheter with a high-level disinfected or sterile forceps
and gently introduce it through the cervix. Ensure that the
inflatable bulb of the catheter is beyond the internal os.
Inflate the bulb with 10 mL of water.
Coil the rest of the catheter and place it in the vagina.
• Leave the catheter in place until contractions begin, or for at least
12 hours.
Deflate the bulb before removing the catheter and then proceed
with oxytocin infusion.
AUGMENTATION OF LABOUR WITH OXYTOCIN

• Infuse oxytocin as described for induction oflabour (page P-19).
Note: Do not use rapid escalation for augmentation of labour.
VACUUM EXTRACTION P-27
Figure P-6 shows the essential components of the vacuum extractor.

FIGUREP-6 Vacuum extractor
A. Assembled
apparatus with
Malmstrom cup
B. Bird modified
cup
• Review for conditions:

vertex presentation;
term fetus;
cervix fully dilated;
ft<tal head at least at 0 station or no more than 2/5 palpable
above symphysis pubis.
Chec]s. all connections and test the vacuum on a gloved hand.
• Provide emotional support and encouragement. If necessary, use a
pudendal block (page P-3).
• Wearing high-level disinfected or sterile gloves, assess the position
of the fetal head by feeling the sagittal suture line and the
fontanelles.
• Identify the posterior fontanelle (Fig P-7, page P-28).
P-28 Vacuum extraction
FIGUREP-7 Landmarks of the fetal skull
• Apply the largest cup that will fit, with the center of the cup over
the flexion point, 1 cm anterior to the posterior fontanelle. This
placement will promote flexion, descent and autorotation with
traction (Fig P-8).
FIGURE P-S Applying the Malmstrom cup
An episiotomy may be needed for proper placement at this time

(page P-71). If an episiotomy is not necessary for placement,
delay the episiotomy until the head stretches the perineum or the
perineum interferes with the axis of traction. This will avoid
unnecessary blood loss.
Check the application. Ensure there is no maternal soft tissue
(cervix or vagina) within the rim.
Vacuum extraction P-29
With the pump, create a vacuum of 0.2 kg/cm2 negative pressure

and check the application.
Increase the vacuum to 0.8 kg/cm2 and check the application.

After maximum negative pressure, start traction in the line of the
pelvic axis and perpendicular to the cup. If the fetal head is tilted
-to one side or not flexed well, traction should be directed in a line
that will try to correct the tilt or deflexion of the head (i.e. to one
side or the other, not necessarily in the midline).
With each contraction, apply traction in a line perpendicular to the
plane of the cup rim (Fig P-9). Place a finger on the scalp next to
the cup during traction to assess potential slippage and descent of
the vertex.
FIGUREP-9 Applying traction
Between contractions check:

fetal heart rate;
application of the cup.
TIPS
Never use the cup to actively rotate the baby's head. Rotation of
the baby's head will occur with traction.
The first pulls help to find the proper direction for pulling.
• Do not continue to pull between contractions and expulsive efforts.
With progress, and in the absence of fetal distress, continue the
"guiding" pulls for a maximum of 30 minutes.
P-30 Vacuum extraction
FAILURE
Vacuum extraction failed if the:
fetal head does not advance with each pull;
fetus is undelivered after three pulls with no descent, or after
30 minutes;
cup slips off the head twice at the proper direction of pull with
a maximum negative pressure.
Every application should be considered a trial of vacuum
extraction. Do not persist if there is no descent with every pull.
If vacuum extraction fails, use vacuum extraction in combination
with symphysiotomy (see below) or perform a caesarean section
(page P-43).
VACUUM EXTRACTION AND SYMPHYSIOTOMY

Vacuum extraction may be used in combination with
symphysiotomy (page P-53) in the following circumstances:
the fetal head is at least at -2 station or no more than 3/5
palpable above the symphysis pubis;
caesarean section is not feasible or immediately available;
the provider is experienced and proficient in symphysiotomy;
vacuum extraction alone has failed or is expected to fail;
there is no major degree of disproportion.
COMPLICATIONS
Complications usually result from not observing the conditions of
application or from continuing efforts beyond the time limits stated
above.
FETAL COMPLICATIONS
Localized scalp oedema (caput succedaneum or chignon) under the
vacuum cup is harmless and disappears in a few hours.
• Cephalohaematoma requires observation and usually will clear in
three to four weeks.
Vacuum extraction P·31
Scalp abrasions (common and harmless) and lacerations may

occur. Clean and examine lacerations to determine if sutures are
necessary. Necrosis is extremely rare.
• Intracranial bleeding is extremely rare and requires immediate
intensive neonatal care.
MATERNAL COMPLICATIONS
Tears of the genital tract may occur. Examine the woman carefully
and repair any tears to the cervix (page P-81) or vagina (page
P-83) or repair episiotomy (page P-73).
P·32 Vacuum extraction
FORCEPS DELIVERY P-33
Review for conditions:

vertex presentation or face presentation with chin-anterior or
entrapped after-coming head in breech delivery (page P-41);
cervix fully dilated;
fetal head at +2 or +3 station or 0/5 palpable above the
symphysis pubis.
At a minimum, the sagittal suture should be in the midline and straight,
guaranteeing an occiput anterior or occiput posterior position.
• Assemble the forceps before application. Ensure that the parts fit
together and lock well.
• Lubricate the blades of the forceps.
• Wearing high-level disinfected or sterile gloves, insert two fingers
of the right hand into the vagina on the side of the fetal head. Slide
the left blade gently between the head and fingers to rest on the
side of the head (Fig P-10).
A biparietal, bimalar application is the only safe application.
FIGUREP-10 Applying the left blade of the forceps
Repeat the same manoeuvre on the other side, using the left hand
and the right blade of the forceps (Fig P-11, page P-34).
P-34 Forceps delivery
FIGUREP-11 Applying the right blade of the forceps
Depress the handles and lock the forceps.

Difficulty in locking usually indicates that the application is
incorrect. In this case, remove the blades and recheck the position
of the head. Reapply only if rotation is confirmed.
After locking, apply steady traction inferiorly and posteriorly with
each contraction (Fig P-12).
FIGUREP-12 Locking and applying traction
• Between contractions check:

fetal heart rate;
application of forceps.
Forceps delivery P·35
• When the head crowns, make an adequate episiotomy, if necessary

(page P-71).
Lift the head slowly out of the vagina between contractions.
The head should descend with each pull. Only two or three pulls should
be necessary.
FAILURE
Forceps failed if:
fetal head does not advance with each pull;
fetus is undelivered after three pulls with no descent or after
30 minutes.
Every application should be considered a trial of forceps. Do not
persist if the head does not descend with every pull.
• If forceps delivery fails, perform a caesarean section (page P-43).
Symphysiotomy is not an option with failed forceps.
COMPLICATIONS
FETAL COMPLICATIONS
• Injury to facial nerves requires observation. This injury usually
resolves spontaneously.
Lacerations of the face and scalp may occur. Clean and examine
lacerations to determine if sutures are necessary.
• Fractures of the face and skull require observation.
MATERNAL COMPLICATIONS
• Tears of the genital tract may occur. Examine the woman carefully
and repair any tears to the cervix (page P-81) or vagina (page
P-83) or repair episiotomy (page p.73).
Uterine rupture may occur and requires immediate treatment (page
P-95).
P-36 Forceps delivery
BREECH DELIVERY P-37
• Review for indications. Ensure that all conditions for safe vaginal
breech delivery are met.
Perform all manoeuvres gently and without undue force.
COMPLETE OR FRANK BREECH

FIGUREP-13 Breech presentation
A. Complete B. Frank
(flexed) (extended)
breech breech
DELIVERY OF THE BUTTOCKS AND LEGS

Once the buttocks have entered the vagina and the cervix is fully
dilated, tell the woman she can bear down with the contractions.
If the perineum is very tight, perform an episiotomy (page P-71).
• Let the buttocks deliver until the lower back and then the shoulder
blades are seen.
Gently hold the buttocks in one hand, but do not pull.
If the legs do not deliver spontaneously, deliver one leg at a time:
Push behind the knee to bend the leg;
Grasp the ankle and deliver the foot and leg;
Repeat for the other leg.
P-38 Breech delivery
Do not pull the baby while the legs are being delivered.
Hold the baby by the hips, as shown in Fig P-14. Do not hold the
baby by the flanks or abdomen as this may cause kidney or liver
damage.
FIGUREP-14 Hold the baby at the hips, but do not pull
~I
DELIVERY OF THE ARMS
ARMS ARE FELT ON CHEST

• Allow the arms to disengage spontaneously one by one. Only assist
if necessary.
• After spontaneous delivery of the first arm, lift the buttocks
towards the mother's abdomen to enable the second arm to deliver
spontaneously.
If the arm does not spontaneously deliver, place one or two
fingers in the elbow and bend the arm, bringing the hand down
over the baby's face.
ARMS ARE STRETCHED ABOVE THE HEAD OR FOLDED

AROUND THE NECK
Use the Lovset's manoeuvre (Fig P-15):
Hold the baby by the hips and turn half a circle, keeping the back
uppermost and applying downward traction at the same time, so
that the arm that was posterior becomes anterior and can be
delivered under the pubic arch.
Assist delivery of the arm by placing one or two fingers on the
upper part of the arm. Draw the arm down over the chest as the
elbow is flexed, with the hand sweeping over the face.
To deliver the second arm, turn the baby back half a circle, keeping
the back uppermost and applying downward traction, and deliver
the second arm in the same way under the pubic arch.
FIGUREP-15 Lovset's manoeuvre
BABY'S BODY CANNOT BE TURNED

If the baby's body cannot be turned to deliver the arm that is
anterior first, deliver the shoulder that is posterior (Fig P-16):
Hold and lift the baby up by the ankies.
Move the baby's chest towards the woman's inner leg. The
shoulder that is posterior should deliver.
Deliver the arm and hand.
Lay the baby back down by the ankles. The shoulder that is
anterior should now deliver.
Deliver the arm and hand.
FIGUREP-16 Delivery of the shoulder that is posterior
DELIVERY OF THE HEAD

Deliver the head by the Mauriceau Smellie Veit manoeuvre (Fig P-17,
page P-41) as follows:
Lay the baby face down with the length of its body over your hand
and arm.
• Place the first and third fingers of this hand on the baby's
cheekbones and place the second finger in the baby's mouth to pull
the jaw down and flex the head.
• Use the other hand to grasp the baby's shoulders.
• With two fingers of this hand, gently flex the baby's head towards
the chest while pulling on the jaw to bring the baby's head down
until the hairline is visible.
• Pull gently to deliver the head.
Note: Ask an assistant to push above the mother's pubic bone as
the head delivers. This helps to keep the baby's head flexed.
• Raise the baby, still astride the arm, until the mouth and nose are
free.
FIGURE P-17 The Mauriceau Smellie Veit manoeuvre
ENTRAPPED(STUCK)HEAD
Catheterize the bladder.
Have an assistant available to hold the baby while applying Piper
or long forceps.
Be sure the cervix is fully dilated.
Wrap the baby's body in a cloth or towel and hold the baby up.
Place the left blade of the forceps.
• Place the right blade and lock handles.

Use the forceps to flex and deliver the baby's head.
If unable to use forceps, apply firm pressure above the mother's
pubic bone to flex the baby's head and push it through the pelvis.
FOOTLING BREECH
A footling breech baby (Fig P-18) should usually be delivered by
FIGUREP-18 Single footling breech presentation, with one leg
extended at hip and knee
Limit vaginal delivery of a footling breech baby to:

advanced labour with fully dilated cervix;
preterm baby that is not likely to survive after delivery;
delivery of additional baby(s) in multiple gestation.
To deliver the baby vaginally:
Grasp the baby's ankles with one hand;
If only one foot presents, insert a hand into the vagina and
gently pull the other foot down;
Gently pull the baby downwards by the ankles;
Deliver the baby until the back and shoulder blades are seen;
Proceed with delivery of the arms (page P-38).
BREECH EXTRACTION
Wearing high-level disinfected or sterile gloves (wear long gloves
if available), insert a hand into the uterus and grasp the baby's foot.
Hold the foot and pull it out through the vagina.
• Gently pull on the foot until the back and shoulder blades are seen.
Proceed with delivery of the arms (page P-38).
• Give a single dose of prophylactic antibiotics after breech
extraction (page C-35):
POST-DELIVERY CARE
• Suction the baby's mouth and nose.
Clamp and cut the cord.
• Give oxytocin 10 units IM within one minute of delivery and
continue active management of the third stage (page C-73).
• Examine the woman carefully and repair any tears to the cervix
(page P-81) or vagina (page P-83) or repair episiotomy (page
P-73).
CAESAREAN SECTION P-43
Review for indications. Ensure that vaginal delivery is not

possible.
Check for fetal life by listening to the fetal heart rate and examine
for fetal presentation.
Review general care principles (page C-17) and operative care
principles (page C-47), and start an IV infusion (page C-21).
• Use spinal anaesthesia (page P-11), local infiltration with
lignocaine (page P-7), ketamine (page P-13) or general
anaesthesia:
Local anaesthesia is a safe alternative to general, ketamine or
spinai anaesthesia when these anaesthetics or persons trained
in their use are not available;
The use of local anaesthesia for caesarean section requires that
the provider counsel the woman and reassure her throughout
the procedure. The provider must keep in mind that the woman
is awake and alert, and should use instruments and handle
tissue as gently as possible.
Note: In the case of heart failure, use local infiltration anaesthesia
with conscious sedation. A void spinal anaesthesia.
Determine if a high vertical incision (page P-50) is indicated:
an inaccessible lower segment due to dense adhesions from
previous caesarean sections;
transverse lie (with baby's back down) for which a lower
uterine segment incision cannot be safely performed;
fetal malformations (e.g. conjoined twins);
large fibroids over the lower segment;
a highly vascular lower segment due to placenta praevia;
carcinoma of the cervix.
If the baby's head is deep down in the pelvis as in obstructed
labour, prepare the vagina for assisted caesarean delivery (page
C-22).
Have the operating table tilted to the left or place a pillow or folded
linen under the woman's right lower back to decrease supine
hypotension syndrome.
P-44 Caesarean section
OPENING THE ABDOMEN

Make a midline vertical incision below the umbilicus to the pubic
hair, through the skin and to the level of the fascia (Fig P-19).
Note: If the caesarean section is performed under local
anaesthesia, make a midline incision that is about 4 cm longer
than when general anaesthesia is used. A Pfannenstiel incision
should not be used, as it takes longer, retraction is poorer and it
requires more local anaesthetic.
FIGUREP-19 Site of abdominal incision
!..-)
l
I
I
I
I
I
.I
• Make a 2-3 cm vertical incision in the fascia.

• Hold the fascia! edge with forceps and lengthen the incision up and
down using scissors.
Use fingers or scissors to separate the rectus muscles (abdominal
wall muscles).
Use fingers to make an opening in the peritoneum near the
umbilicus. Use scissors to lengthen the incision up and down in
order to see the entire uterus. Carefully, to prevent bladder injury,
use scissors to separate layers and open the lower part of the
peritoneum.
Place a bladder retractor over the pubic bone.
Use forceps to pick up the loose peritoneum covering the anterior
surface of the lower uterine segment and incise with scissors.
Extend the incision by placing the scissors between the uterus and
the loose serosa and cutting about 3 cm on each side in a transverse
fashion.
Use two fingers to push the bladder downwards off of the lower
uterine segment. Replace the bladder retractor over the pubic bone
and bladder.
OPENING THE UTERUS
• Use a scalpel to make a 3 cm transverse incision in the lower
segment of the uterus. It should be about 1 cm below the level
where the vesico-uterine serosa was incised to bring the bladder
down.
Widen the incision by placing a finger at each edge and gently
pulling upwards and laterally at the same time (Fig P-20).
If the lower uterine segment is thick and narrow, extend the
incision in a crescent shape, using scissors instead of fingers to
avoid extension of the uterine vessels.
It is important to make the uterine incision big enough to deliver

the head and body of the baby without tearing the incision.
FIGUREP-20 Enlarging the uterine incision
DELIVERY OF THE BABY AND PLACENTA

• To deliver the baby, place one hand inside the uterine cavity
between the uterus and the baby's head.
With the fingers, grasp and flex the head.
• Gently lift the baby's head through the incision (Fig P-21, page,
P-46), taking care not to extend the incision down towards the cervix.
With the other hand, gently press on the abdomen over the top of
the uterus to help deliver the head.
If the baby's head is deep down in the pelvis or vagina, ask an

assistant (wearing high-level disinfected or sterile gloves) to reach
into the vagina and push the baby's head up through the vagina.
Then lift and deliver the head (Fig P-22).
FIGUREP-21 Delivering the baby's head
FIGUREP-22 Delivering the deeply engaged head
• Suction the baby's mouth and nose when delivered.

• Deliver the shoulders and body.
Give oxytocin 20 units in 1 L IV fluids (normal saline or Ringer's
lactate) at 60 drops per minute for two hours.
Clamp and cut the umbilical cord.
• Hand the baby to the assistant for initial care (page C-76).
• Give a single dose of prophylactic antibiotics after the cord is
clamped and cut (page C-35):
ampicillin 2 g IV;
OR cefazolin 1 g IV.
• Keep gentle traction on the cord and massage (rub) the uterus
through the abdomen.
Deliver the placenta and membranes. Use ring forceps to ensure
that all membranes are removed.
CLOSING THE UTERINE INCISION

Note: If a Couvelaire uterus (swollen and discoloured by blood)
is seen at caesarean section, close it in the normal manner. Observe
for bleeding and assess uterine tone. Be prepared to manage
coagulopathy (page S-19) or atonic uterus (page S-28).
• Grasp the corners of the uterine incision with clamps.
• Grasp the edges of the incision with clamps. Make sure it is
separate from the bladder.
• Look carefully for any extensions of the uterine incision.
• Repair the incision and any extensions with a continuous locking
stitch of 0 chromic catgut (or poly glycolic) suture (Fig P-23).
If there is any further bleeding from the incision site, close with
figure-of-eight sutures. There is no need for a routine second layer
of sutures in the uterine incision.
FIGUREP-23 Closing the uterine incision
CLOSING THE ABDOMEN

Look carefully at the uterine incision before closing the abdomen.
Make sure there is no bleeding and the uterus is firm. Use a sponge
to remove any clots inside the abdomen.
• Examine carefully for injuries to the bladder and repair any found
(page P-97).
Close the fascia with continuous 0 chromic catgut (or polyglycolic)
suture.
Note: There is no need to close the bladder peritoneum or the
abdominal peritoneum.
If there are signs of infection, pack the subcutaneous tissue with
gauze and place loose 0 catgut (or polyglycolic) sutures. Close the
skin with a delayed closure after the infection has cleared.
If there are no signs of infection, close the skin with vertical
mattress sutures of 3-0 nylon (or silk) and apply a sterile dressing.
• Gently push on the abdomen over the uterus to remove clots from
the uterus and vagina.
PROBLEMS DURING SURGERY
BLEEDING IS NOT CONTROLLED

Massage the uterus.
If the uterus is atonic, continue to infuse oxytocin and give
ergometrine 0.2 mg IM and prostaglandins, if available. These
drugs can be given together or sequentially (Table S-8, page
S-28).
• Transfuse as necessary (page C-23).
• Have an assistant press fingers over the aorta to reduce the
bleeding until the source of bleeding can be found and stopped.
If bleeding is not controlled, perform uterine and utero-ovarian
artery ligation (page P-99) or hysterectomy (page P-103).
Caesarean section P·49
BABY IS BREECH
If the baby is breech, grasp a foot and deliver it through the
incision.
Complete the delivery as in a vaginal breech delivery (page P-37):
Deliver the legs and the body up to the shoulders, then deliver
the arms;
Flex (bend) the head using the Mauriceau Smellie Veit
manoeuvre (page P-40).
BABY IS TRANSVERSE
THE BABY'S BACK IS UP

• If the back is up (near the top of the uterus), reach into the uterus
and find the baby's ankles.
• Grasp the ankles and pull gently through the incision to deliver the
legs and complete the delivery as for a breech baby (page P-38).
THE BABY'S BACK IS DOWN

If the back is down, a high vertical uterine incision is the preferred
incision (page P-50).
• After the incision is made, reach into the uterus and find the feet.
Pull them through the incision and complete the delivery as for a
breech baby {page P-38).
• To repair the vertical incision, you will need several layers of
suture (page P-50).
PLACENTA PRAEVIA
If a low anterior placenta is encountered, incise through it and
deliver the fetus.
After delivery of the baby, if the placenta cannot be detached
manually, the diagnosis is placenta accreta, a common finding at
the site of a previous caesarean scar. Perform a hysterectomy (page
P-103).
Women with placenta praevia are at high risk of postpartum
haemorrhage. If there is bleeding from the placental site, under-
run the bleeding sites with chromic catgut (or polyglycolic) sutures.
P·50 Caesarean section
Watch for bleeding in the immediate postpartum period and take

appropriate action (page S-25).
POST-PROCEDURE CARE
• Review postoperative care principles (page C-52).
• If bleeding occurs:
Massage the uterus to expel blood and blood clots. Presence of
blood clots will inhibit effective uterine contractions;
Give oxytocin 20 units in 1 L IV fluids (normal saline or
Ringer's lactate) at 60 drops per minute and ergometrine 0.2 mg
IM and prostaglandins (Table S-8, page S-28). These drugs
can be given together or sequentially.
If there are signs of infection or the woman currently has fever,
give a combination of antibiotics until she is fever-free for 48 hours
(page C-35):
Give appropriate analgesic drugs (page C-37).
HIGH VERTICAL ("CLASSICAL") INCISION

Open the abdomen through a midline incision skirting the
umbilicus. Approximately one-third of the incision should be above
the umbilicus and two-thirds below.
• Use a scalpel to make the incision:
Check the position of the round ligaments and ensure that the
incision is in the midline (the uterus may have twisted to one
side);
Make the uterine incision in the midline over the fundus of the
uterus;
The incision should be approximately 12-15 cm in length and
the lower limit should not extend to the utero-vesical fold of the
peritoneum.
Ask an assistant (wearing high-level disinfected or sterile gloves) to

apply pressure on the cut edges to control the bleeding.
Cut down to the level of the membranes and then extend the incision
using scissors.
After rupturing the membranes, grasp the baby's foot and deliver the
baby.
Deliver the placenta and membranes.
Grasp the edges of the incision with Allis or Green Arrnytage
forceps.
• Close the incision using at least three layers of suture:
Close the first layer closest to the cavity, but avoiding the
decidua, with a continuous 0 chromic catgut (or polyglycolic)
suture;
Close the second layer of uterine muscle using interrupted 1
chromic catgut (or polyglycolic) sutures;
Close the superficial fibres and the serosa using a continuous 0
chromic catgut (or polyglycolic) suture with an atraumatic
needle.
Close the abdomen as for lower segment caesarean section (page
P-48).
The woman should not labour with future pregnancies.
TUBAL LIGATION AT CAESAREAN

Tuballigation can be done immediately following caesarean section if
the woman requested the procedure before labour began (during prenatal
visits). Adequate counselling and informed decision-making and consent
must precede voluntary sterilization procedures; this is often not possible
during labour and delivery.
• Review for consent of patient.
Grasp the least vascular, middle portion of the fallopian tube with a
Babcock or Allis forceps.
Hold up a loop of tube 2.5 cm in length (Fig P-24 A, page P-52).
• Crush the base of the loop with artery forceps and ligate it with 0
plain catgut suture (Fig P-24 B, page P-52).
Excise the loop (a segment 1 cm in length) through the crushed area
(Fig P-24 C-D).
Repeat the procedure on the other side.
FIGUREP-24 Tuballigation
A. Holding up a loop
of the fallopian tube \
B. Crushing the base of the loop with forceps

and ligating it in a figure-of-eight fashion
C. Crushed area (with line D. Excising the loop

of resection indicated of the fallopian
by dotted line) tube
SYMPHYSIOTOMY P-53
Symphysiotomy results in a temporary increase in pelvic diameter (up
to 2 cm) by surgically dividing the ligaments of the symphysis under
local anaesthesia. This procedure should be carried out only in
combination with vacuum extraction (page P-27). Symphysiotomy in
combination with vacuum extraction is a life-saving procedure in areas
where caesarean section is not feasible or immediately available.
Symphysiotomy leaves no uterine scar and the risk of ruptured uterus in
future labours is not increased.
These benefits must, however, be weighed against the risks of the
procedure. Risks include urethral and bladder injury, infection, pain and
long-term walking difficulty. Symphysiotomy should, therefore, be
carried out only when there is no safe alternative.
Review for indications:
contracted pelvis;
vertex presentation;
prolonged second stage;
failure to descend after proper augmentation;
AND failure or anticipated failure of vacuum extraction alone.
• Review conditions for symphysiotomy:
fetus is alive;
cervix is fully dilated;
fetal head at -2 station or no more than 3/5 above the
symphysis pubis;
no over-riding of the head above the symphysis;
caesarean section is not feasible or immediately available;
the provider is experienced and proficient in symphysiotomy.
Provide emotional support and encouragement. Use local
infiltration with lignocaine (page C-38).
Ask two assistants to support the woman's legs with her thighs and
knees flexed. The thighs should be abducted no more than 45
degrees from the midline (Fig P-25, page P-54).
P-54 Symphysiotomy
Abduction of the thighs more than 45 degrees from the

midline may cause tearing of the urethra and bladder.
FIGUREP-25 Position of the woman for symphysiotomy
Perform a mediolateral episiotomy (page P-71). If an episiotomy

is already present, enlarge it to minimize stretching of the vaginal
wall and urethra.
Infiltrate the anterior, superior and inferior aspects of the
symphysis with lignocaine 0.5% solution (page C-39).
suffer convulsions and death if IV injection occurs.
then pinch the incision site with forceps. If the woman feels the
Insert a firm catheter to identify the urethra.

• Apply antiseptic solution to the suprapubic skin (page C-22).
Symphysiotomy P·55
• Wearing high-level disinfected or sterile gloves, place an index

finger in the vagina and push the catheter, and with it the urethra,
away from the midline (Fig P-26).
FIGUREP-26 Pushing urethra to one side after inserting the
catheter
• With the other hand, use a thick, frrm-bladed scalpel to make a

vertical stab incision over the symphysis.
• Keeping to the midline, cut down through the cartilage joining the
two pubic bones until the pressure of the scalpel blade is felt on the
finger in the vagina.
• Cut the cartilage downwards to the bottom of the symphysis, then
rotate the blade and cut upwards to the top of the symphysis.
• Once the symphysis has been divided through its whole length, the
pubic bones will separate.
FIGUREP-27 Dividing the cartilage
P-56 Symphysiotomy
After separating the cartilage, remove the catheter to decrease

urethral trauma.
• Deliver by vacuum extraction (page P-27). Descent of the head
causes the symphysis to separate 1 or 2 cm.
• After delivery, catheterize the bladder with a self-retaining bladder
catheter.
There is no need to close the stab incision unless there is bleeding.
POST-PROCEDURE CARE
• If there are signs of infection or the woman cnrrently has fever,
give a combination of antibiotics until she is fever-free for 48
hours (page C-35):
Apply elastic strapping across the front of the pelvis from one iliac
crest to the other to stabilize the symphysis and reduce pain.
Leave the catheter in the bladder for a minimum of five days.
Encourage the woman to drink plenty of fluids to ensure a good
urinary output.
Encourage bed rest for seven days after discharge from hospital.
• Encourage the woman to begin to walk with assistance when she is
ready to do so.
• If long-term walking difficulties and pain are reported (occur in
2% of cases), treat with physical therapy.
CRANIOTOMY AND CRANIOCENTESIS P·57
In certain cases of obstructed labour with fetal death, reduction in the
size of the fetal head by craniotomy makes vaginal delivery possible
and avoids the risks associated with caesarean delivery. Craniocentesis
can be used to reduce the size of a hydrocephalic head to make vaginal
delivery possible.
Provide emotional support and encouragement. If necessary, give
diazepam IV slowly or use a pudendal block (page P-3).
CRANIOTOMY (skull perforation}

Review general care principles (page C-17) and apply antiseptic
solution to the vagina (page C-22).
• Perform an episiotomy, if required (page P-71).
CEPHALIC PRESENTATION
• Make a cruciate (cross-shaped) incision on the scalp (Fig P-28).
FIGUREP-28 Cruciate incision on scalp
/ '"
.::.:L·.
·~·
~
Open the cranial vault at the lowest and most central bony point
with a craniotome (or large pointed scissors or a heavy scalpel). In
face presentation, perforate the orbits.
• Insert the craniotome into the fetal cranium and fragment the
intracranial contents.
P·58 Craniotomy and craniocentesis
Grasp the edges of the skull with several heavy-toothed forceps

(e.g. Kocher) and apply traction in the axis of the birth canal (Fig
P-29).
FIGUREP-29 Extraction by scalp traction
As the head descends, pressure from the bony pelvis will cause the
skull to collapse, decreasing the cranial diameter.
If the head is not delivered easily, perform caesarean section
(page P-43).
• After delivery, examine the woman carefully and repair any tears
to the cervix (page P-81) or vagina (page P-83), or repair
episiotomy (page P-73).
Leave a self-retaining catheter in place until it is confirmed that
there is no bladder injury.
Ensure adequate fluid intake and urinary output.
BREECH PRESENTATION WITH ENTRAPPED HEAD

Make an incision through the skin at the base of the neck.
Insert a craniotome (or large pointed scissors or a heavy scalpel)
through the incision and tunnel subcutaneously to reach the
occiput.
Perforate the occiput and open the gap as widely as possible.
• Apply traction on the trunk to collapse the skull as the head
descends.
Craniotomy and craniocentesis P-59
CRANIOCENTESIS (skull puncture)

solution to the vagina (page C-22).
• Make a large episiotomy, if required (page P-71).
FULLY DILATED CERVIX

Pass a large-bore spinal needle through the dilated cervix and
through the sagittal suture line or fontanelles of the fetal skull (Fig
P-30).
Aspirate the cerebrospinal fluid until the fetal skull has collapsed,
and allow normal delivery to proceed.
FIGUREP-30 Craniocentesis with a dilated cervix
CLOSED CERVIX
Palpate for location of fetal head.
Apply antiseptic solution to the suprapubic skin (page C-22).
Pass a large-bore spinal needle through the abdominal and uterine
walls and through the hydrocephalic skull.
Aspirate the cerebrospinal fluid until the fetal skull has collapsed,
and allow normal delivery to proceed.
P-60 Craniotomy and craniocentesis
AFTERCOMING HEAD DURING BREECH DELIVERY

After the rest of the body has been delivered, insert a large-bore
spinal needle through the dilated cervix and foramen magnum (Fig
P-31).
Aspirate the cerebrospinal fluid and deliver the aftercoming head
as in breech delivery (page P-40).
FIGUREP-31 Craniocentesis of the aftercoming head
DURING CAESAREAN SECTION

After the uterine incision is made, pass a large-bore spinal needle
through the hydrocephalic skull.
Aspirate the cerebrospinal fluid until the fetal skull has collapsed.
Deliver the baby and placenta as in caesarean section (page P-45).
POST-PROCEDURE CARE
After delivery, examine the woman carefully and repair any tears
to the cervix (page P-81) or vagina (page P-83), or repair
episiotomy (page P-73).
Leave a self-retaining catheter in place until it is confirmed that
there is no bladder injury.
Ensure adequate fluid intake and urinary output.
DILATATION AND CURETTAGE P·61
The preferred method of evacuation of the uterus is by manual vacuum
aspiration (page P-65). Dilatation and curettage should be used only
if manual vacuum aspiration is not available.
Review for indications (page P-65).
• Provide emotional support and encouragement. Give pethidine IM
or IV before the procedure or use a paracervical block (page P-1).
• Administer oxytocin 10 units IM or ergometrine 0.2 mg IM before
the procedure to make the myometrium firmer and reduce the risk
of perforation.
Perform a bimanual pelvic examination to assess the size and
position of the uterus and the condition of the fornices.
Insert a speculum or vaginal retractor into the vagina.
Apply antiseptic solution to the vagina and cervix (especially the
os) (page C-22).
Check the cervix for tears or protruding products of conception. If
products of conception are present in the vagina or cervix,
remove them using ring or sponge forceps.
Gently grasp the anterior or posterior lip of the cervix with a
vulsellum or single-toothed tenaculum (Fig P-32, page P-62).
Note: With incomplete abortion, a ring or sponge forceps is
preferable, as it is less likely than the tenaculum to tear the cervix
placement.
If using a tenaculum to grasp the cervix, first inject 1 mL of
Dilatation is needed only in cases of missed abortion or when some
retained products of conception have remained in the uterus for
several days:
Gently introduce the widest gauge cannula or curette;
Use graduated dilators only if the cannula or curette will not
pass. Begin with the smallest dilator and end with the largest
dilator that ensures adequate dilatation (usually 10-12 mm)
(Fig P-33, page P-62);
Take care not to tear the cervix or to create a false opening.
P-62 Dilatation and curettage
FIGUREP-32 Inserting a retractor and holding the anterior lip

of the cervix
Anterior lip
of cervix
Retractor
FIGUREP-33 Dilating the cervix
Dilator
Gently pass a uterine sound through the cervix to assess the length
and direction of the uterus.
The uterus is very soft in pregnancy and can be easily injured

during this procedure.
Evacuate the contents of the uterus with ring forceps or a large

curette (Fig P-34, page P-63). Gently curette the walls of the
uterus until a grating sensation is felt.
Dilatation and curettage P-63
FIGUREP-34 Curetting the uterus
Remove the speculum or retractors and perform a bimanual pelvic

examination to check the size and firmness of the uterus.
• Examine the evacuated material (page P-67). Send material for
histopathologic examination, if required.
POST-PROCEDURE CARE
• Give paracetamol 500 mg by mouth as needed.
• Encourage the woman to eat, drink and walk about as she wishes.
• Offer other health services, if possible, including tetanus
prophylaxis, counselling or a family planning method (page S-12).
Discharge uncomplicated cases in one to two hours.
• Advise the woman to watch for symptoms and signs requiring
immediate attention:
prolonged cramping (more than a few days);
prolonged bleeding (more than two weeks);
bleeding more than normal menstrual bleeding;
severe or increased pain;
fever, chills or malaise;
fainting.
P-64 Dilatation and curettage
MANUAL VACUUM ASPIRATION P-65
• Review for indications for manual vacuum aspiration (MV A;

inevitable abortion before 16 weeks, incomplete abortion, molar
pregnancy or delayed PPH due to retained placental fragments).
Provide emotional support and encouragement and give
paracetamol30 minutes before the procedure. Use a paracervical
block may if necessary (page P-1).
Prepare the MV A syringe:
Assemble the syringe;
Close the pinch valve;
Pull back on the plunger until the plunger arms lock.
Note: For molar pregnancy, when the uterine contents are likely to
be copious, have three syringes ready for use.
Even if bleeding is slight, give oxytocin 10 units IM or ergometrine
0.2 mg IM before the procedure to make the myometrium firmer
and reduce the risk of perforation.
Perform a bimanual pelvic examination to assess the size and
position of the uterus and the condition of the fornices.
Insert a speculum or vaginal retractor into the vagina.
Apply antiseptic solution to the vagina and cervix (especially the
os) (page C-22).
Check the cervix for tears or protruding products of conception. If
products of conception are present in the vagina or cervix,
remove them using ring or sponge forceps.
Gently grasp the anterior or posterior lip of the cervix with a
vulsellum or single-toothed tenaculum.
Note: With incomplete abortion, a ring or sponge forceps is
preferable as it is less likely than the tenaculum to tear the cervix
placement.
If using a tenaculum to grasp the cervix, first inject 1 mL of
• Dilatation is needed only in cases of missed abortion or when
products of conception have remained in the uterus for several days:
P-66 Manual vacuum aspiration
Gently introduce the widest gauge suction cannula;

Use graduated dilators only if the cannula will not pass. Begin
with the smallest dilator and end with the largest dilator that
ensures adequate dilatation (usually 10-12 mm) (Fig P-33,
page P-62);
Take care not to tear the cervix or to create a false opening.
While gently applying traction to the cervix, insert the cannula
through the cervix into the uterine cavity just past the internal os
(Fig P-35). (Rotating the cannula while gently applying pressure
often helps the tip of the cannula pass through the cervical canal.)
FIGUREP-35 Inserting the cannula
Slowly push the cannula into the uterine cavity until it touches the
fundus, but not more than 10 cm. Measure the depth of the uterus by
dots visible on the cannula and then withdraw the cannula slightly.
Attach the prepared MV A syringe to the cannula by holding the
vulsellum (or tenaculum) and the end of the cannula in one hand
and the syringe in the other.
Release the pinch valve(s) on the syringe to transfer the vacuum
through the cannula to the uterine cavity.
Evacuate remaining uterine contents by gently rotating the syringe
from side to side (10 to 12 o'clock) and then moving the cannula
gently and slowly back and forth within the uterine cavity (Fig
P-36, page P-67).
Note: To avoid losing the vacuum, do not withdraw the cannula
opening past the cervical os. If the vacuum is lost or if the syringe is
more than half full, empty it and then re-establish the vacuum.
Manual vacuum aspiration P-67
Note: Avoid grasping the syringe by the plunger arms while the
vacuum is established and the cannula is in the uterus. If the
plunger arms become unlocked, the plunger may accidentally slip
back into the syringe, pushing material back into the uterus.
FIGUREP-36 Evacuating the contents of the uterus
Check for signs of completion:
Red or pink foam but no more tissue is seen in the cannula;

A grating sensation is felt as the cannula passes over the
surface of the evacuated uterus;
The uterus contracts around (grips) the cannula.
• Withdraw the cannula. Detach the syringe and place the cannula in
decontamination solution.
With the valve open, empty the contents of the MVA syringe into a
strainer by pushing on the plunger.
Note: Place the empty syringe on a high-level disinfected or sterile
tray or container until you are certain the procedure is complete.
Remove the speculum or retractors and perform a bimanual
examination to check the size and firmness of the uterus.
• Quickly inspect the tissue removed from the uterus:
for quantity and presence of products of conception;
to assure complete evacuation;
to check for a molar pregnancy (rare).
If necessary, strain and rinse the tissue to remove excess blood
clots, then place in a container of clean water, saline or weak acetic
P·68 Manual vacuum aspiration
acid (vinegar) to examine. Tissue specimens may also be sent for

histopathologic examination, if required.
• If no products of conception are seen:
All of the products of conception may have been passed before
the MVA was performed (complete abortion);
The uterine cavity may appear to be empty but may not have
been emptied completely. Repeat the evacuation;
The vaginal bleeding may not have been due to an incomplete
abortion (e.g. breakthrough bleeding, as may be seen with
hormonal contraceptives or uterine fibroids);
The uterus may be abnormal (i.e. cannula may have been
inserted in the nonpregnant side of a double uterus).
Note: Absence of products of conception in a woman with
symptoms of pregnancy raises the strong possibility of ectopic
pregnancy (page S-13).
Gently insert a speculum into the vagina and examine for bleeding.
If the uterus is still soft and not smaller or if there is persistent,
brisk bleeding, repeat the evacuation.
POST-PROCEDURE CARE
Encourage the woman to eat, drink and walk about as she wishes.
Offer other health services, if possible, including tetanus
prophylaxis, counselling or a family planning method (page S-12).
• Discharge uncomplicated cases in one to two hours.
• Advise the woman to watch for symptoms and signs requiring
immediate attention:
prolonged cramping (more than a few days);
prolonged bleeding (more than two weeks);
bleeding more than normal menstrual bleeding;
severe or increased pain;
fever, chills or malaise;
fainting.
CULDOCENTESIS AND COLPOTOMY P·69
CULDOCENTESIS
solution to the vagina (especially the posterior fornix) (page C-22).
Provide emotional support and encouragement. If necessary, use
local infiltration with lignocaine (page C-38).
Gently grasp the posterior lip of the cervix with a tenaculum and
gently pull to elevate the cervix and expose the posterior vagina.
Place a long needle (e.g. spinal needle) on a syringe and insert it
through the posterior vagina, just below the posterior lip of the
cervix (Fig P-37).
FIGUREP-37 Diagnostic puncture of the cui-de-sac
Tenaculum
Pull back on the syringe to aspirate the cui-de-sac (the space

behind the uterus).
• If non-clotting blood is obtained, suspect ectopic pregnancy (page
S-13).
If clotting blood is obtained, a vein or artery may have been
aspirated. Remove the needle, re-insert it and aspirate again.
If clear or yellow fluid is obtained, there is no blood in the
peritoneum. The woman may, however, still have an unruptured
ectopic pregnancy and further observations and tests may be
needed (page S-13).
P-70 Culdocentesis and colpotomy
If no fluid is obtained, remove the needle, re-insert it and aspirate

again. If no fluid is obtained, the woman may have an unruptured
ectopic pregnancy (page S-13).
If pus is obtained, keep the needle in place and proceed to
colpotomy (see below).
COLPOTOMY
If pus is obtained on culdocentesis, keep the needle in place and make
a stab incision at the site of the puncture:
Remove the needle and insert blunt forceps or a finger through the
incision to break loculi in the abscess cavity (Fig P-38).
FIGUREP-38 Colpotomy for pelvic abscess
Tenaculum
• Allow the pus to drain.

Insert a high-level disinfected or sterile soft rubber corrugated drain
through the incision.
Note: A drain can be prepared by cutting off the fingertips of a
high-level disinfected or sterile examination glove.
If required, use a stitch through the drain to anchor it in the vagina.
Remove the drain when there is no more drainage of pus.
If no pus is obtained, the abscess may be higher than the pouch of
Douglas. A laparotomy will be required for peritoneal lavage
(wash-out).
EPISIOTOMY P-71
Episiotomy should not be performed routinely.
Episiotomy should be <eORsidered only in the case of:

• complicated vaginal delivery (breech, shoulder dystocia,
forceps, vacuum extraction);
• scarring from female genital cutting or poorly healed third or
fourth degree tears;
fetal distress.
• Review general care principles (page C-17) and apply antiseptic

solution to the perineal area (page C-22).
infiltration with lignocaine (page C-38) or a pudendal block (page
P-3).
Make sure there are no known allergies to lignocaine or related drugs.
Infiltrate beneath the vaginal mucosa, beneath the skin of the
perineum and deeply into the perineal muscle (Fig P-39, page
P-72) using about 10 mL 0.5% lignocaine solution (page C-39).
occurs.
then pinch the incision site with forceps. If the woman feels the

P-72 Episiotomy
FIGUREP-39 Infiltration of perineal tissue with local anaesthetic
Wait to perform episiotomy until:

the perineum is thinned out; and
3-4 cm of the baby's head is visible during a contraction.
Performing an episiotomy will cause bleeding. It should not,

therefore, be done too early.
Wearing high-level disinfected or sterile gloves, place two fingers

between the baby's head and the perineum.
Use scissors to cut the perineum about 3-4 cm in the mediolateral
direction (Fig P-40, page P-73).
Use scissors to cut 2-3 cm up the middle of the posterior vagina.
Control the baby's head and shoulders as they deliver, ensuring
that the shoulders have rotated to the midline to prevent an
extension of the episiotomy.
Carefully examine for extensions and other tears and repair (see
below).
Episiotomy P·73
FIGUREP-40 Making the incision while inserting two fingers to

protect the baby's head
REPAIR OF EPISIOTOMY
Note: It is important that absorbable sutures be used for closure.

Polyglycolic sutures are preferred over chromic catgut for their
tensile strength, non-allergenic properties and lower probability
of infectious complications and episiotomy breakdown. Chromic
catgut is an acceptable alternative, but is not ideal.
Apply antiseptic solution to the area around the episiotomy (page

C-22).
If the episiotomy is extended through the anal sphincter or rectal
mucosa, manage as third or fourth degree tears, respectively (page
P-86).
Close the vaginal mucosa using continuous 2-0 suture (Fig P-41 A,
pageP-74):
Start the repair about I cm above the apex (top) of the
episiotomy. Continue the suture to the level of the vaginal
opening;
At the opening of the vagina, bring together the cut edges of
the vaginal opening;
P-74 Episiotomy
Bring the needle under the vaginal opening and out through
the incision and tie.
Close the perineal muscle using interrupted 2-0 sutures
(Fig P-41 B).
Close the skin using interrupted (or subcuticular) 2-0 sutures (Fig
P-41 C).
FIGUREP-41 Repair of episiotomy
'· ..
!-~,~:;,
A. Vaginal mucosa B. Musde layer C. Skin
COMPLICATIONS
If a haematoma occurs, open and drain. If there are no signs of
infection and bleeding has stopped, reclose the episiotomy.
If there are signs of infection, open and drain the wound. Remove
infected sutures and debride the wound:
If the infection is mild, antibiotics are not required;
If the infection is severe but does not involve deep tissues,
give a combination of antibiotics (page C-35):
days;
day for five days.
If the infection is deep, involves muscles and is causing
necrosis (necrotizing fasciitis), give a combination of
Episiotomy P-75
antibiotics until necrotic tissue has been removed and the

hours;
ampicillin 500 mg by mouth four times per day for
five days;
PLUS metronidazole 400 mg by mouth three times
per day for five days.
Perform delayed primary closure in two to four weeks (depending
on resolution of the infection).
P-76 Episiotomy
MANUAL REMOVAL OF PLACENTA P-n
• Review for indications.
Provide emotional support and encouragement. Give pethidine and
diazepam IV slowly (do not mix in the same syringe) or use
ketamine (page P-13).
Catheterize the bladder or ensure that it is empty.
Give a single dose of prophylactic antibiotics (page C-35):
OR cefazolin I g IV PLUS metronidazole 500 mg IV.
Hold the umbilical cord with a clamp. Pull the cord gently until it
is parallel to the floor.
• Wearing high-level disinfected or sterile gloves (use long gloves if
available), insert the other hand into the vagina and up into the
uterus (Fig P-42).
FIGURE P-42 Introducing one hand into the vagina along cord
• Let go of the cord and move the hand up over the abdomen in order
to support the fundus of the uterus and to provide counter-traction
during removal to prevent inversion of the uterus (Fig P-43, page
P-78).
Note: If uterine inversion occurs, reposition the uterus (page P-91).
Move the fingers of the hand in the uterus laterally until the edge
of the placenta is located.
• If the cord has been detached previously, insert a hand into the
uterine cavity. Explore the entire cavity until a line of cleavage is
identified between the placenta and the uterine wall.
P-78 Manual removal of placenta
FIGUREP-43 Supporting the fundus while detaching the placenta
• Detach the placenta from the implantation site by keeping the

fingers tightly together and using the edge of the hand to gradually
make a space between the placenta and the uterine wall.
Proceed slowly all around the placental bed until the whole
placenta is detached from the uterine wall.
If the placenta does not separate from the uterine surface by
gentle lateral movement of the fingertips at the line of cleavage,
remove placental fragments (page S-32). If the tissue is very
adherent, suspect placenta accreta and proceed to laparotomy and
possible subtotal hysterectomy (page P-103).
Hold the placenta and slowly withdraw the hand from the uterus,
bringing the placenta with it (Fig P-44).
• With the other hand, continue to provide counter-traction to the
fundus by pushing it in the opposite direction of the hand that is
being withdrawn.
FIGUREP-44 Withdrawing the hand from the uterus
Manual removal of placenta P-79
Palpate the inside of the uterine cavity to ensure that all placental
tissue has been removed.
Give oxytocin 20 units in 1 L IV fluids (normal saline or Ringer's
lactate) at 60 drops per minute.
• Ask an assistant to massage the fundus of the uterus to encourage a
tonic uterine contraction.
If there is continued heavy bleeding, give ergometrine 0.2 mg IM
or prostaglandins (Table S-8, page S-28).
Examine the uterine surface of the placenta to ensure that it is
complete. If any placental lobe or tissue is missing, explore the
uterine cavity to remove it.
Examine the woman carefully and repair any tears to the cervix
(page P-81) or vagina (page P-83), or repair episiotomy
(page P-73).
PROBLEMS
If the placenta is retained due to a constriction ring or if hours
or days have passed since delivery, it may not be possible to get
the entire hand into the uterus. Extract the placenta in fragments
using two fingers, ovum forceps or a wide curette (page S-32).
POST-PROCEDURE CARE
Observe the woman closely until the effect of IV sedation has worn
off.
Monitor vital signs (pulse, blood pressure, respiration) every 30
minutes for the next six hours or until stable.
Palpate the uterine fundus to ensure that the uterus remains
contracted.
Check for excessive lochia.
Continue infusion of IV fluids.
Transfuse as necessary (page C-23).
P-80 Manual removal of placenta
REPAIR OF CERVICAL TEARS P-81

solution to the vagina and cervix (page C-22).
• Provide emotional support and encouragement. Anaesthesia is not
required for most cervical tears. For tears that are high and
extensive, give pethidine and diazepam IV slowly (do not mix in
the same syringe) or use ketarnine (page P-13).
Ask an assistant to gently provide fundal pressure to help push the
cervix into view.
Use vaginal retractors as necessary to expose the cervix.
• Gently grasp the cervix with ring or sponge forceps. Apply the
forceps on both sides of the tear and gently pull in various
directions to see the entire cervix. There may be several tears.
• Close the cervical tears with continuous 0 chromic catgut (or
polyglycolic) suture starting at the apex (upper edge of tear), which
is often the source of bleeding (Fig P-45).
• If a long section of the rim of the cervix is tattered, under-run it
with continuous 0 chromic catgut (or polyglycolic) suture.
If the apex is difficult to reach and ligate, grasp it with artery or
ring forceps. Leave the forceps in place for four hours. Do not
persist in attempts to ligate the bleeding points as such attempts
may increase the bleeding. Then:
After four hours, open the forceps partially but do not remove;
After another four hours, remove the forceps completely.
Note: A laparotomy may be required to repair a cervical tear that has
extended deep beyond the vaginal vault.
FIGUREP-45 Repair of a cervical tear
Apex
P-82 Repair of cervical tears
REPAIR OF VAGINAL AND PERINEAL TEARS P-83
There are four degrees of tears that can occur during delivery:
First degree tears involve the vaginal mucosa and connective
tissue.
Second degree tears involve the vaginal mucosa, connective tissue
and underlying muscles.
• Third degree tears involve complete transection of the anal
sphincter.
Fourth degree tears involve the rectal mucosa.
Note: It is important that absorbable sutures be used for closure.

Polyglycolic sutures are preferred over chromic catgut for their
tensile strength, non-allergenic properties and lower probability
of infectious complications. Chromic catgut is an acceptable
alternative, but is not ideal.
REPAIR OF FIRST AND SECOND DEGREE TEARS

Most first degree tears close spontaneously without sutures.
• Review general care principles (page C-17).
infiltration with lignocaine (page C-38). If necessary, use a
• Ask an assistant to check the uterus and ensure that it is contracted.
Carefully examine the vagina, perineum and cervix (Fig P-46,
page P-84).
If the tear is long and deep through the perineum, inspect to be
sure there is no third or fourth degree tear:
Place a gloved finger in the anus;
Gently lift the finger and identify the sphincter;
Feel for the tone or tightness of the sphincter.
Change to clean, high-level disinfected or sterile gloves.
• If the sphincter is injured, see the section on repair of third and
fourth degree tears (page P-86).
If the sphincter is not injured, proceed with repair.
P·84 Repair of vaginal and perineal tears
FIGUREP-46 Exposing a perineal tear
Apply antiseptic solution to the area around the tear (page C-22).
• Make sure there are no known allergies to lignocaine or related drugs.
Note: If more than 40 mL of lignocaine solution will be needed
for the repair, add adrenaline to the solution (page C-39).
• Infiltrate beneath the vaginal mucosa, beneath the skin of the
perineum and deeply into the perineal muscle using about 10 mL
0.5% lignocaine solution (page C-39).
occurs.
then pinch the area with forceps. If the woman feels the pinch,
• Repair the vaginal mucosa using a continuous 2-0 suture

(Fig P-47, page P-85):
Start the repair about 1 cm above the apex (top) of the vaginal
tear. Continue the suture to the level of the vaginal opening;
At the opening of the vagina, bring together the cut edges of
the vaginal opening;
Bring the needle under the vaginal opening and out through
the perineal tear and tie.
FIGUREP-47 Repairing the vaginal mucosa
retractor ·_ , ·/_._- __
Anterior-£__, ( . '
\ . ,/1.
}f-.·
1 !
\ ;X~>;~-.-----c-----~~·J-.
·,=~:
I -0',
?){-.- __ -_-
~~v''·~
.(,r- ·.
-L '-J/
Repair the perineal muscles using interrupted 2-0 suture

(Fig P-48). If the tear is deep, place a second layer of the same
stitch to close the space.
FIGUREP-48 Repairing the perineal muscles
Repair the skin using interrupted (or subcuticular) 2-0 sutures

starting at the vaginal opening (Fig P-49, page P-86).
If the tear was deep, perform a rectal examination. Make sure no
stitches are in the rectum.
P-86 Repair of vaginal and perineal tears
FIGUREP-49 Repairing the skin
-~
/-
REPAIR OF THIRD AND FOURTH DEGREE PERINEAL TEARS

Note: The woman may suffer loss of control over bowel movements
and gas if a tom anal sphincter is not repaired correctly. If a tear in the
rectum is not repaired, the woman can suffer from infection and
rectovaginal fistula (passage of stool through the vagina).
Repair the tear in the operating room.
• Review general care principles (page C-17).
Provide emotional support and encouragement. Use a pudendal
block (page P-3), ketamine (page P-13) or spinal anaesthesia
(page P-11). Rarely, if all edges of the tear can be seen, the repair
can be done using local infiltration with lignocaine (see above) and
pethidine and diazepam IV slowly (do not mix in the same
syringe).
Ask an assistant to check the uterus and ensure that it is contracted.
Examine the vagina, cervix, perineum and rectum.
• To see if the anal sphincter is tom:
Place a gloved finger in the anus and lift slightly;
Identify the sphincter, or lack of it;
Feel the surface of the rectum and look carefully for a tear.
Change to clean, high-level disinfected or sterile gloves.
• Apply antiseptic solution to the tear and remove any faecal

material, if present (page C-22).
Make sure there are no known allergies to lignocaine or related drugs.
• Infiltrate beneath the vaginal mucosa, beneath the skin of the
perineum, and deeply into the perineal muscle using about 10 mL
0.5% lignocaine solution (page C-39).
occurs.
then pinch the area with forceps. If the woman feels the pinch,
Repair the rectum using interrupted 3-0 or 4-0 sutures 0.5 cm apart
to bring together the mucosa (Fig P-50):
Remember: Place the suture through the muscularis (not all the
way through the mucosa).
Cover the muscalaris layer by bringing together the fascial
layer with interrupted sutures;
Apply antiseptic solution to the area frequently.
FIGUREP-50 Closing the muscle wall of the rectum
If the sphincter is torn:

Grasp each end of the sphincter with an Allis clamp (the
sphincter retracts when torn). The fascial sheath around the
sphincter is strong and will not tear when pulling with the
clamp (Fig P-51, page P-88);
Repair the sphincter with two or three interrupted stitches of 2-0
suture.
FIGUREP-51 Suturing the anal sphincter
Apply antiseptic solution to the area again.

Examine the anus with a gloved finger to ensure the correct repair
of the rectum and sphincter. Then change to clean, high-level
disinfected or sterile gloves.
• Repair the vaginal mucosa, perineal muscles and skin (page P-84).
POST-PROCEDURE CARE
• If there is a fourth degree tear, give a single dose of prophylactic
antibiotics (page C-35):
ampicillin 500 mg by mouth;
PLUS metronidazole 400 mg by mouth.
Follow up closely for signs of wound infection.
A void giving enemas or rectal examinations for two weeks.
Give stool softener by mouth for one week, if possible.
MANAGEMENT OF NEGLECTED CASES

A perineal tear may be contaminated with faecal material. If closure is
delayed more than 12 hours, infection is likely. Delayed primary
closure is indicated in such cases.
For first and second degree tears, have the woman return in six
days. If there are no signs of infection, proceed with delayed
primary closure.
For third and fourth degree tears, close the rectal mucosa with
some supporting tissue and approximate the fascia of the anal
sphincter with two or three sutures. Close the muscle and vaginal
mucosa and the perineal skin six days later.
COMPLICATIONS
If a haematoma is observed, open and drain it. If there are no
signs of infection and the bleeding has stopped, the wound can
be reclosed.
If there are signs of infection, open and drain the wound. Remove
infected sutures and debride the wound:
If the infection is mild, antibiotics are not required;
If the infection is severe but does not involve deep tissues,
give a combination of antibiotics (page C-35):
days;
day for five days.
If the infection is deep, involves muscles and is causing
necrosis (necrotizing fasciitis), give a combination of
antibiotics until necrotic tissue has been removed and the
hours;
ampicillin 500 mg by mouth four times per day for

five days;
PLUS metronidazole 400 mg by mouth three times
per day for five days.
Perform delayed primary closure in two to four weeks
(depending on resolution of the infection).
Faecal incontinence may result from complete sphincter
transection. Many women are able to maintain control of
defaecation by the use of other perineal muscles. When
incontinence persists, reconstructive surgery must be performed
three months or more after delivery.
Rectovaginal fistula requires reconstructive surgery three months
or more postpartum.
CORRECTING UTERINE INVERSION P-91

Give pethidine and diazepam IV slowly (do not mix in the same
syringe). If necessary, use general anaesthesia.
Thoroughly cleanse the inverted uterus using antiseptic solution.
Apply compression to the inverted uterus with a moist, warm
sterile towel until ready for the procedure.
MANUAL CORRECTION
Wearing high-level disinfected or sterile gloves, grasp the inverted
uterus and push it through the cervix in the direction of the umbilicus
to its normal anatomic position, using the other hand to stabilize the
uterus (Fig P-52). If the placenta is still attached, manually remove
the placenta after correction.
It is important that the part of the uterus that came out last
(the part closest to the cervix) goes in first.
FIGUREP-52 Manual replacement of the inverted uterus
Supporting
hand---+-
If correction is not achieved, proceed to hydrostatic correction

(page P-92).
P-92 Correcting uterine inversion
HYDROSTATIC CORRECTION
Place the woman in deep Trendelenburg position (lower her head
about 0.5 metres below the level of the perineum).
Prepare a high-level disinfected or sterile douche system with large
nozzle and long tubing (2 metres) and a warm water reservoir (3 to
5 L).
Note: This can also be done using warmed normal saline and an
ordinary IV administration set.
Identify the posterior fornix. This is easily done in partial inversion
when the inverted uterus is still in the vagina. In other cases, the
posterior fornix is recognized by where the rugose vagina becomes
the smooth vagina.
Place the nozzle of the douche in the posterior fornix.
• At the same time, with the other hand hold the labia sealed over the
nozzle and use the forearm to support the nozzle.
Ask an assistant to start the douche with full pressure (raise the
water reservoir to at least 2 metres). Water will distend the
posterior fornix of the vagina gradually so that it stretches. This
causes the circumference of the orifice to increase, relieves cervical
constriction and results in correction of the inversion.
MANUAL CORRECTION UNDER GENERAL ANAESTHESIA

If hydrostatic correction is not successful, try manual
repositioning under general anaesthesia using halothane. Halothane
is recommended because it relaxes the uterus .
.Grasp the inverted uterus and push it through the cervix in the
direction of the umbilicus to its normal anatomic position, using
the other hand to stabilize the uterus (Fig P-52, page P-91). If the
placenta is still attached, manually remove the placenta after
correction.
COMBINED ABDOMINAL-VAGINAL CORRECTION

Abdominal-vaginal correction under general anaesthesia may be
required if the above measures fail.
Correcting uterine inversion P-93
Review operative care principles (page C-47).

Open the abdomen:
Make a midline vertical incision below the umbilicus to the
pubic hair, through the skin and to the level of the fascia;
Make a 2-3 cm vertical incision in the fascia;
Hold the fascial edge with forceps and lengthen the incision up
and down using scissors;
Use fingers or scissors to separate the rectus muscles
(abdominal wall muscles);
Use fingers or scissors to make an opening in the peritoneum
near the umbilicus. Use scissors to lengthen the incision up
and down. Carefully, to prevent bladder injury, use scissors to
separate layers and open the lower part of the peritoneum;
Place a bladder retractor over the pubic bone and place self-
retaining abdominal retractors.
• Dilate the constricting cervical ring digitally.
Place a tenaculum through the cervical ring and grasp the inverted
fundus.
• Apply gentle continuous traction to the fundus while an assistant
attempts manual correction vaginally.
• If traction fails:
Incise the constricting cervical ring vertically and posteriorly
(where the incision is least likely to injure the bladder or
uterine vessels);
Repeat digital dilatation, tenaculum and traction steps;
Close the constriction ring.
If correction is successful, close the abdomen:
Make sure there is no bleeding. Use a sponge to remove any
clots inside the abdomen;
Close the fascia with continuous 0 chromic catgut (or
polyglycolic) suture;
P-94 Correcting uterine inversion
If there are signs of infection, pack the subcutaneous tissue

with gauze and place loose 0 catgut (or polyglycolic) sutures.
Close the skin with a delayed closure after the infection has
cleared;
mattress sutures of 3-0 nylon (or silk) and apply a sterile
dressing.
POST-PROCEDURE CARE
Once the inversion is corrected, infuse oxytocin 20 units in 500 mL
IV fluids (normal saline or Ringer's lactate) at 10 drops per
minute:
If haemorrhage is suspected, increase the infusion rate to 60
drops per minute;
If the uterus does not contract after oxytocin, give
ergometrine 0.2 mg or prostaglandins (Table S-8, page S-28).
• Give a single dose of prophylactic antibiotics after correcting the
inverted uterus (page C-35):
If combined abdominal-vaginal correction was used, see
postoperative care principles (page C-52).
hours (page C-35):
• Give appropriate analgesic drugs (page C-37).
REPAIR OF RUPTURED UTERUS P-95

ampicillin 2 g IV;
Open the abdomen:
Hold the fascia! edge with forceps and lengthen the incision up
umbilicus. Use scissors to lengthen the incision up and down
in order to see the entire uterus. Carefully, to prevent bladder
injury, use scissors to separate layers and open the lower part
of the peritoneum;
Examine the abdomen and the uterus for site of rupture and
remove clots;
Deliver the baby and placenta.
Infuse oxytocin 20 units in 1 L IV fluids (normal saline or Ringer's
lactate) at 60 drops per minute until the uterus contracts and then
reduce to 20 drops per minute.
Lift the uterus out of the pelvis in order to note the extent of the injury.
Examine both the front and the back of the uterus.
Hold the bleeding edges of the uterus with Green Armytage clamps
(or ring forceps).
Separate the bladder from the lower uterine segment by sharp or
blunt dissection. If the bladder is scarred to the uterus, use fine
scissors.
P-96 Repair of ruptured uterus
RUPTURE THROUGH CERVIX AND VAGINA

If the uterus is torn through the cervix and vagina, mobilize the
bladder at least 2 cm below the tear.
If possible, place a suture 2 cm above the lower end of the cervical
tear and keep traction on the suture to bring the lower end of the
tear into view as the repair continues.
RUPTURE LATERALLY THROUGH UTERINE ARTERY

If the rupture extends laterally to damage one or both uterine
arteries, ligate the injured artery.
Identify the arteries and ureter prior to ligating the uterine vessels
(Fig P-53, page P-100).
RUPTURE WITH BROAD LIGAMENT HAEMATOMA

If the rupture has created a broad ligament haematoma (Fig
S-2, page S-20), clamp, cut and tie off the round ligament.
Open the anterior leaf of the broad ligament.
Drain off the haematoma manually, if necessary.
Inspect the area carefully for injury to the uterine artery or its
branches. Ligate any bleeding vessels·.
REPAIRING THE UTERINE TEAR

Repair the tear with a continuous locking stitch of 0 chromic catgut
(or polyglycolic) suture. If bleeding is not controlled or if the
rupture is through a previous classical or vertical incision,
place a second layer of suture.
Ensure that the ureter is identified and exposed to avoid

including it in a stitch.
If the rupture is too extensive for repair, proceed with

hysterectomy (page P-103).
Repair of ruptured uterus P-97
Control bleeding by clamping with long artery forceps and ligating.

If the bleeding points are deep, use figure-of-eight sutures.
If the woman has requested tuballigation, perform the procedure
at this time (page P-51).
Place an abdominal drain (page C-51).
Close the abdomen:
Ensure that there is no bleeding. Remove clots using a sponge.
In all cases, check for injury to the bladder. If a bladder
injury is identified, repair the injury (see below).
poly glycolic) suture.
Note: There is no need to close the bladder peritoneum or
the abdominal peritoneum.
If there are signs of infection, pack the subcutaneous tissue with
gauze and place loose 0 catgut (or polyglycolic) sutures. Close
the skin with a delayed closure after the infection has cleared.
dressing.
REPAIR OF BLADDER INJURY

• Identify the extent of the injury by grasping each edge of the tear
with a clamp and gently stretching. Determine if the injury is close
to the bladder trigone (ureters and urethra).
Dissect the bladder off the lower uterine segment with fine scissors
or with a sponge on a clamp.
Free a 2 cm circle of bladder tissue around the tear.
Repair the tear in two layers with continuous 3-0 chromic catgut
(or polyglycolic) suture:
Suture the bladder mucosa (thin inner layer) and bladder
muscle (outer layer);
Invert (fold) the outer layer over the first layer of suture and
place another layer of suture;
Ensure that sutures do not enter the trigone area.
P·98 Repair of ruptured uterus
• Test the repair for leaks:

Fill the bladder with sterile saline or water through the
transurethral catheter;
If leaks are present, remove the suture, repair and test again.
If it is not certain that the repair is well away from the ureters
and urethra, complete the repair and refer the woman to a higher-
level facility for an intravenous pyelogram.
Keep the bladder catheter in place for at least seven days and until
urine is clear. Continue IV fluids to ensure flushing of the bladder,
and encourage the woman to drink fluids.
POST-PROCEDURE CARE
Review postoperative care principles (page C-52).
hours (page C-35):
If there are no signs of infection, remove the abdominal drain after
48 hours.
Offer other health services, if possible (page S-13).
• If tuballigation was not performed, offer family planning (Table
S-3, page S-13). If the woman wishes to have more children,
advise her to have elective caesarean section for future
pregnancies.
Because there is an increased risk of rupture with subsequent

pregnancies, the option of permanent contraception needs to
be discussed with the woman after the emergency is over.
Permanent contraception should not be performed without
informed consent from the woman.
UTERINE AND UTERO-OVARIAN ARTERY P-99
LIGATION
• Give a single dose of prophylactic antibiotics (page C-35):
ampicillin 2 g IV;
OR cefazolin I g IV.
Open the abdomen:
of the peritoneum;
Pull on the uterus to expose the lower part of the broad ligament.
Feel for pulsations of the uterine artery near the junction of the
uterus and cervix.
• Using 0 chromic catgut (or polyglycolic) suture on a large needle,
pass the needle around the artery and through 2-3 cm of
myometrium (uterine muscle) at the level where a transverse lower
uterine segment incision would be made. Tie the suture securely.
Place the sutures as close to the uterus as possible, as the ureter is
generally only 1 cm lateral to the uterine artery.
Repeat on the other side.
If the artery has been torn, clamp and tie the bleeding ends.
P-100 Uterine and utero-ovarian artery ligation
Ligate the utero-ovarian artery just below the point where the
ovarian suspensory ligament joins the uterus (Fig P-53).
• Repeat on the other side.
Observe for continued bleeding or formation of haematoma.
FIGUREP-53 Sites for ligating uterine and utero-ovarian
arteries
Close the abdomen:

Ensure that there is no bleeding. Remove clots using a sponge;
Examine carefully for injuries to the bladder and repair any
found (page P-97);
cleared;
mattress sutures of 3-0 nylon (or silk) and apply a sterile dressing.
POST-PROCEDURE CARE
Uterine and utero-ovarian artery ligation P-101
Monitor urine output. If there is blood in the urine or the woman

has loin pain, refer the woman to a tertiary centre, if possible, for
treatment of an obstructed ureter.
hours (page C-35):
48 hours.
Offer other health services, if possible (page S-13).
P-102 Uterine and utero-ovarian artery ligation
POSTPARTUM HYSTERECTOMY P-103
Postpartum hysterectomy can be subtotal (supracervical) unless the

cervix and lower uterine segment are involved. Total hysterectomy
may be necessary in the case of a tear of the lower segment that extends
into the cervix or bleeding after placenta praevia.
ampicillin 2 g IV;
• If there is uncontrollable haemorrhage following vaginal
delivery, keep in mind that speed is essential. To open the
abdomen:
of the peritoneum;
If the delivery was by caesarean section, clamp the sites of
bleeding along the uterine incision:
In case of massive bleeding, have an assistant press fingers
over the aorta in the lower abdomen. This will reduce
intraperitoneal bleeding;
Extend the skin incision, if needed.
P-104 Postpartum hysterectomy
SUBTOTAL (SUPRACERVICAL) HYSTERECTOMY

• Lift the uterus out of the abdomen and gently pull to maintain
traction.
Doubly clamp and cut the round ligaments with scissors (Fig P-54).
Clamp and cut the pedicles, but ligate after the uterine arteries are
secured to save time.
FIGUREP-54 Dividing the round ligaments
• From the edge of the cut round ligament, open the anterior leaf of
the broad ligament. Incise to:
the point where the bladder peritoneum is reflected onto the
lower uterine surface in the midline; or
the incised peritoneum at a caesarean section.
Use two fingers to push the posterior leaf of the broad ligament
forward, just under the tube and ovary, near the uterine edge. Make a
hole the size of a finger in the broad ligament, using scissors. Doubly
clamp and cut the tube, the ovarian ligament and the broad ligament
through the hole in the broad ligament (Fig P-55, page P-105).
The ureters are close to the uterine vessels. The ureter must be
identified and exposed to avoid injuring it during surgery or
including it in a stitch.
FIGUREP-55 Dividing the tube and ovarian ligaments
Divide the posterior leaf of the broad ligament downwards towards

the uterosacral ligaments, using scissors.
Grasp the edge of the bladder flap with forceps or a small clamp.
Using fingers or scissors, dissect the bladder downwards off of the
lower uterine segment. Direct the pressure downwards but inwards
toward the cervix and the lower uterine segment.
Reposition the bladder blade and retract the bladder inferiorly.
• Locate the uterine artery and vein on each side of the uterus. Feel
for the junction of the uterus and cervix.
Doubly clamp across the uterine vessels at a 90 degree angle on
each side of the cervix. Cut and doubly ligate with 0 chromic
catgut (or polyglycolic) suture (Fig P-56).
FIGUREP-56 Dividing the uterine vessels
P-1 06 Postpartum hysterectomy
Observe carefully for any further bleeding. If the uterine arteries

are ligated correctly, bleeding should stop and the uterus should
look pale.
• Return to the clamped pedicles of the round ligaments and tubo-
ovarian ligaments and ligate them with 0 chromic catgut (or
polyglycolic) suture.
Amputate the uterus above the level where the uterine arteries are
ligated, using scissors (Fig P-57).
FIGUREP-57 Line of amputation
Close the cervical stump with interrupted 2-0 or 3-0 chromic catgut
(or polyglycolic) sutures.
Carefully inspect the cervical stump, leaves of the broad ligament
and other pelvic floor structures for any bleeding.
If slight bleeding persists or a clotting disorder is suspected,
place a drain through the abdominal wall (page C-51). Do not
place a drain through the cervical stump, as this can cause
postoperative infection.
Close the abdomen:
In all cases, check for injury to the bladder. If a bladder
injury is identified, repair the injury (page P-97);

cleared;
dressing.
TOTAL HYSTERECTOMY
The following additional steps are required for total hysterectomy:
Push the bladder down to free the top 2 cm of the vagina.
Open the posterior leaf of the broad ligament.
Clamp, ligate and cut the uterosacral ligaments.
• Clamp, ligate and cut the cardinal ligaments, which contain the
descending branches of the uterine vessels. This is the critical step
in the operation:
Grasp the ligament vertically with a large-toothed clamp (e.g.
Kocher);
Place the clamp 5 mm lateral to the cervix and cut the
ligament close to the cervix, leaving a stump medial to the
clamp for safety;
If the cervix is long, repeat the step two or three times as
needed.
The upper 2 cm of the vagina should now be free of attachments.
Circumcise the vagina as near to the cervix as possible, clamping
bleeding points as they appear.
Place haemostatic angle sutures, which include round, cardinal and
uterosacral ligaments.
Place continuous sutures on the vaginal cuff to stop haemorrhage.
Close the abdomen (as above) after placing a drain in the
extraperitoneal space near the stump of the cervix (page C-51).
P-108 Postpartum hysterectomy
POST-PROCEDURE CARE
• Monitor urine output. If there is blood in the urine or the woman
has loin pain, refer the woman to a tertiary centre, if possible, for
treatment of an obstructed ureter.
hours (page C-35):
48 hours.
• Offer other health services, if possible (page S-13).
SALPINGECTOMY FOR ECTOPIC PREGNANCY P-109

ampicillin 2 g IV;
Open the abdomen:
Hold the fascia) edge with forceps and lengthen the incision up
of the peritoneum;
Identify and bring to view the fallopian tube with the ectopic
gestation and its ovary.
Apply traction forceps (e.g. Babcock) to increase exposure and
clamp the mesosalpinx to stop haemorrhage.
Aspirate blood from the lower abdomen and remove blood clots.
Apply gauze moistened with warm saline to pack off the bowel and
omentum from the operative field.
Divide the mesosalpinx using a series of clamps (Fig P-58 A-C,
page P-110). Apply each clamp close to the tubes to preserve
ovarian vasculature.
Transfix and tie the divided mesosalpinx with 2-0 chromic catgut
(or polyglycolic) suture before releasing the clamps.
P-110 Salpingectomy for ectopic pregnancy
Place a proximal suture around the tube at its isthmic end and
excise the tube.
FIGURE P-58 Clamping, dividing and cutting the mesosalpinx
A Clamping mesosalpinx
B. Dividing mesosalpinx C. Placing a proximal

suture around the tube
Close the abdomen:

cleared;
dressing.
Salpingectomy for ectopic pregnancy P-111
SALPINGOSTOMY
Rarely, when there is little damage to the tube, the gestational sac can
be removed and the tube conserved. This should be done only in cases
where the conservation of fertility is very important to the woman since
she is at risk for another ectopic pregnancy.
Open the abdomen and expose the appropriate ovary and fallopian
tube (page P-109).
Apply traction forceps (e.g. Babcock) on either side of the
unruptured tubal pregnancy and lift to view.
• Use a scalpel to make a linear incision through the serosa on the
side opposite to the mesentery and along the axis of the tube, but
do not cut the gestational sac.
Use the scalpel handle to slide the gestational sac out of the tube.
• Ligate bleeding points.
• Return the ovary and fallopian tube to the pelvic cavity.
Close the abdomen (page P-110).
POST-PROCEDURE CARE
hours (page C-35):
• Give appropriate analgesic drugs (page C-37).
• Offer other health services, if possible (page S-13).
If salpingostomy was performed, advise the woman of the risk for
another ectopic pregnancy and offer family planning (Table S-3,
page S-13).
P-112 Salpingectomy for ectopic pregnancy
SECTION 4
APPENDIX
ESSENTIAL DRUGS FOR MANAGING A-1
COMPLICATIONS IN PREGNANCY AND CHILDBIRTH
ANTIBIOTICS IV FLUIDS
Amoxicillin Dextrose 10%
Ampicillin Glucose (5%, 10%, 50%)
Benzathine penicillin Normal saline
Benzyl penicillin Ringer's lactate
Cefazolin
Ceftriaxone ANTICONVULSANTS
Cloxacillin
Erythromycin Diazepam
Gentamicin Magnesium sulfate
Kanamycin Phenytoin
Metronidazole
Nitrofurantoin ANTIHYPERTENSIVES
Penicillin G
Procaine penicillin G Hydralazine
Labetolol
.Trimethoprim/Sulfamethoxazole
Nifedipine
STEROIDS
OXYTOCICS
Betamethasone
Dexamethasone 15-methyl prostaglandin F2a
Hydrocortisone Ergometrine
Methyl ergometrine
Misoprostol
DRUGS USED IN Oxytocin
EMERGENCIES Prostaglandin E2
Adrenaline
Aminophylline
Atropine sulfate ANAESTHETICS
Calcium gluconate Halothane
Digoxin Ketamine
Diphenhydramine Lignocaine 2% or 1%
Ephedrine
Frusemide
Naloxone
ANALGESICS
Nitroglycerine Indomethacin
Prednisone Morphine
Prednisolone Paracetamol
Promethazine Pethidine
A-2 Essential drugs for managing complications in pregnancy and childbirth
SEDATIVES
Diazepam
Phenobarbitone
ANTIMALARIAL
Artemether
Artesunate
Chloroquine
Clindamycin
Mefloquine
Quinidine
Quinine dihydrochloride
Quinine sulfate
Sulfadoxine/Pyrimethamine
TOCOLYTICS
Indomethacin
Nifedipine
Ritodrine
Salbutamol
Terbutaline
OTHER
Anti-tetanus serum
Ferrous fumerate
Ferrous sulfate
Folic acid
Heparin
Magnesium trisilicate
Sodium citrate
Tetanus antitoxin
Tetanus toxoid
Vitamin K
INDEX A-3
Abdominal distension
diagnosis of Abruptio placentae (cont.)
early pregnancy, S-9, S-14 prelabour rupture of membranes
late pregnancy, S-18 and, S-136
Abdominal pain Abscess

diagnosis of diagnosis, S-1 08
early pregnancy, S-116 ~anage~ent
late pregnancy and postpartum, breast, S-113
S-120 pelvic, S-110
general~anage~ent,S-115, wound, S-113
S-119
Acetone
Abdominal palpation presence in urine, C-71
assessment of descent by, C-61
Active management
Abdominal wounds, S-113 third stage of labour, C-73,
P-42
Abnormalities of fetus fetal death, S-133
assessment, S-14 7
emotional considerations, C-12 Acute pyelonephritis
diagnosis, S-100
Abortion ~anage~ent, S-102
see also Manual vacuum appendicitis, confusion with,
aspiration; Dilatation and S-115
curettage
diagnosis, S-8 AIDS
~anage~ent see Infection prevention
complete, S-12
incomplete, S-11 Allergies
inevitable, S-11 lignocaine, C-41
threatened, S-10
complications of, S-9 Amnionitis
family planning after, S-13 diagnosis, S-136
follow-up treatment, S-12 ~anage~ent, S-139
tetanus, unsafe abortions and, prelabour rupture of
S-51 membranes and, S-136
types of abortion, S-10
Amniotic fluid
Abruptio placentae see also Prelabour rupture of
diagnosis, S-18 membranes
~anage~ent, S-18 testing for, S-137
A-4 Index
Amniotomy Anaesthesia and analgesia (cont.)

see Artificial rupture of paracervical block, P-1
membranes postoperative, C-46
premedication, C-21, C-38
Anaemia pudendal block, P-3
diagnosis, S-126 spinal, P-11
management
malaria and, S-56 Anal sphincter tears
postpartum, S-26 see Vaginal or perineal tears
severe, S-127
haemoglobin or haematocrit Analgesia
determinations, S-26 see Anaesthesia and analgesia
heart failure and, S-127
malaria and, S-56, S-1 03 Antibiotics, C-35
spinal anaesthesia, avoidance of,
P-11 Antidepressants
breast feeding and, C-13
Anaesthesia and analgesia
see also Pain management Antiseptics
general principles, C-43 chlorhexidine, C-22, C-49
administration, timing of, C-21, iodophors, C-22, C-49
C-38
caesarean section, options for, Anxiety
P-7, P-43 dealing with, C-5
emotional support and, C-43 shock and anxiousness, S-1
injection techniques, C-41, P-1
ketamine, P-13 Appendicitis
local anaesthesia diagnosis, S-116
general discussion, C-38 management, S-117
adrenaline and, C-39 diagnostic confusion, S-115,
allergic reactions, C-41 S-119
caesarean section, use during, gravid uterus and, S-119
P-7
cardiac arrest, C-43 Artificial rupture of membranes
respiratory arrest, C-42 see also Rupture of membranes
toxicity, C-41, C-42, C-43 procedure, P-17
vomiting, C-41, C-46
narcotics Asthma
during labour, C-59 see Bronchial asthma
postoperative, C-46
respiratory depression in Atelectasis
newborn and, C-38 diagnosis, S-1 09
options, C-45
Index A-5
Atonic uterus Bleeding (cont.)

diagnosis, S-27 shock causation, S-4
management, S-28 uterus, bimanual compression
of, S-29
Augmentation of labour
see Induction and augmentation Blood and blood products
of labour see also Transfusion
general principles, C-23
Birth control coagulopathy, managment, S-19
see Family planning compatibility tests, C-25
infection prevention, C-24
Birth defects plasma transfusions, C-24
emotional considerations, C-12 prescribing, C-27
epilepsy, treatment and, S-51 screening for infectious agents,
malformations, S-147 C-25
septic shock, C-29
Bladder unnecessary use, C-23
catheterization, C-48 whole blood or red cell
infection, S-1 0 I transfusions, C-24
postoperative care, C-54
repair of injury, P-97 Blood pressure
see also Hypertension
Bleeding diastolic, measuring of, S-36
see also Haemorrhage; proteinuria, pre-eclampsia and,
Coagulopathy S-37, S-39
diagnosis of shock and low blood pressure,
early pregnancy, S-8 S-1
labour, S-17, S-18
later pregnancy, S-17, S-18 Blurred vision
postpartum, S-27 diagnosis of, C-41, S-38
general management
early pregnancy, S-7 Breast abscess
labour, S-17 diagnosis, S-108
later pregnancy, S-17 management,S-113
postpartum, S-26 breastfeeding, S-113
antepartum, S-7, S-17
aorta, compression of, S-30 Breast engorgement
caesarean section, control diagnosis, S-108
during, P-48 management,S-111
light or heavy, S-8
loss measurement, S-25 Breast infections
packing uterus, S-30 see Breast abscess; Mastitis
postpartum, S-25
A-6 Index
Breastfeeding Breech presentation and delivery

antidepressant drugs and, C-13 (cont.)
complications Mauriceau Smellie Veit
breast abscess, S-113 manoeuvre, P-40, P-41
breast engorgement, S-111 meconium-staining and, S-96
mastitis, S-112 multiple pregnancy and, S-90
delay in initial feeding, C-78 post-delivery care, P-42
initiating, C-76, C-78
Bronchial asthma
Breathing diagnosis, S-126
techniques during labour, C-58 management, S-129
Breathing difficulty Bronchitis, S-129

see also Cyanosis; Respiratory
arrest Bronchospasm
diagnosis of, S-126 bronchial asthma and, S-129
generalmanagement,S-125 transfusion caused, C-28
newboms, S-141
resuscitation planning, C-73 Brow presentation
oxygen administration, S-146, diagnosis, S-73
S-147 management, S-76
preterm babies, S-147
shock and rapid breathing, S-1 Caesarean section
procedure, P-43
Breech presentation and delivery anaesthesia options, C-45, P-7,
see also Malpositions or P-11, P-43
malpresentation antibiotics, C-35
diagnosis, S-74 bleeding control, P-48
management, S-79 postoperative, P-50
delivery procedure, P-37 breech presentation and, P-49
anaesthesia options, C-45, P-3 classical incision, P-50
caesarean section and, S-80, P-49 closing abdomen, P-48
complete breech, S-74, S-79, closing uterus, P-47
P-37 heart failure and, P-43, S-128
complications, S-80 high-vertical incision, P-50
craniotomy and, P-58 hysterectomy after, P-103
external version, correction by, oxytocin use in subsequent
S-79, P-15 pregnancy, P-21
extraction, P-42 placenta praevia and, P-49
footling breech, P-41 placenta, delivery of, P-45
frank breech, S-74, S-79, P-37 postoperative care, P-50
head, entrapped, P-41 prolapsed cord and, S-97
Lovset's manoeuvre, P-38, P-39 transverse lie and, P-49
Index A-7
Caesarean section (cont.) Cervix

tuballigation after, P-51 see also Tears
induction of labour, assessment
Cannula of cervix prior to, P-18
infusion, insertion for, C-21 paracervical block, P-1
venous cutdown, insertion by, ripening, P-24
S-3 ruptured uterus involving, repair,
P-96
Cardiac arrest
anaesthesia reactions, C-43 Clotting disorders
see Coagulopathy
Catheterization
see Bladder Coagulopathy
diagnosis
Cellulitis bedside clotting test, S-2
wound cellulitis, S-114 management, S-19
eclampsia, caesarean
Cephalohaematoma delivery and, S-47
vacuum extraction and, P-30 spinal anaesthesia, avoidance
of, P-11
Cephalopelvic disproportion
diagnosis, S-57 Colloid solutions
management, S-65 replacement fluids, use as,
C-31
Cerebral haemorrhage
hypertension and, S-48 Colpotomy
procedure, P-70
Cervical dilatation anaesthesia options, C-45
labour, diagnosis and
confirmation of, C-60 Coma
diagnosis of, S-38, S-39
Cervical tears
repair, P-81 Communication techniques
anaesthesia options, C-45 general principles, C-6
bleeding caused by, S-31 labour and childbirth, C-57
forceps delivery and, P-35
vacuum extraction and, P-31 Community linkages, C-79
Cervicitis Companion, support

diagnosis, S-136 see Family members
Foley catheter, dangers of use of,
P-25
A-8 Index
Compound presentation Craniocentesis (cont.)

diagnosis, S-74 emotional considerations, C-11
management, S-78 post-procedure care, P-60
Confusion Craniotomy
shock and, S-1 procedure
breech presentation, P-58
Congenital syphilis cephalic presentation, P-57
management in newboms, anaesthesia options, C-45, P-3
S-150 emotional considerations, C-11
post-procedure care, P-60
Consciousness
see Loss of consciousness Culdocentesis
procedure, P-69
Contractions anaesthesia options, C-45
false labour and cessation of,
S-64 Curettage
inadequate and prolonged labour, see Dilatation and curettage
S-63, S-66
partograph, recording of, C-66 Cyanosis
see also Breathing and
Convulsions breathing difficulty
diagnosis of, S-38, S-39 diagnosis of, S-126
lignocaine toxicity and, C-42 newboms, S-141, S-146
newborn, S-141, S-149
Cystitis
Cord diagnosis, S-100
see also Prolapsed cord management, S-101
delivery, checking during, C-72
traction, placental delivery by, Deep vein thrombosis, S-1 09
C-74, S-31
pulsations and prolapsed cord, Delivery
S-97 see Labour and childbirth
Cough Depression
diagnosis of, S-126 antidepressant drugs, breast
feeding and, C-13
Craniocentesis postpartum, emotional
procedure considerations, C-13
breech presentation, P-60
caesarean section and, P-60 Descent
closed cervix, P-59 assessment of, C-61
dilated cervix, P-59
Index A-9
Dextran Eclampsia and pre-eclampsia

shock and danger of (cont.)
administration, S-2 S-39
anticonvulsive drugs, S-44
Dextrose solutions antihypertensive drugs, S-46
acetone in urine, used for, C-71 convulsions, S-40, S-43, S-44
maintenance fluids, use as, C-31, degrees of pre-eclampsia, S-38
C-32 delivery mandates, S-47
replacement fluids, use as, mild pre-eclampsia, S-42
C-30 oedema and pre-eclampsia, S-39,
subcutaneous, danger of S-126
administration, C-33 proteinuria and pre-eclampsia,
S-37, S-39
Dilatation pulmonary oedema and
see Cervical dilatation pre-eclampsia, S-126
severe pre-eclampsia and
Dilatation and curettage eclampsia, S-43
see also Vacuum aspiration spinal anaesthesia, avoidance of,
procedure, P-61 P-11
anaesthesia options, C-45, P-1,
P-11 Ectopic pregnancy
complications, P-63 diagnosis, S-8, S-13, S-14
post-procedure care, P-63 culdocentesis, P-69
management, S-14
Diuretics appendicitis, confusion with,
mild pre-eclampsia and danger of S-115
administration of, S-42 salpingectomy or salpingostomy,
P-109
Drainage vaginal bleeding in early
surgical procedures and, C-51 pregnancy and, S-7
Dressing Edema
surgical procedures and, C-52 see Oedema
Dyspareunia Elevated blood pressure

diagnosis of, S-136 see Blood pressure
Dysuria Emergency response procedures

diagnosis of, S-1 00, S-136 planning for, C-15
rapid initial assessment, C-3
Eclampsia and pre-eclampsia
diagnosis, S-37, S-38 Emotional support
general management, S-35, general principles, C-7
A-10 Index
Emotional support (cont.) Family planning

labour, anxiety during, C-58 abortion and, S-12, S-13
pain management and, C-43 methods, S-13
molar pregnancy and, S-16
Encephalitis ruptured uterus, post-repair
diagnosis, S-39 counselling, P-98
tuballigation during caesarean
Enemas section, P-51
labour, avoidance of use during, salpingostomy, post-procedure
C-58 counselling, P-111
Epilepsy Fasciitis
diagnosis, S-39 necrotizing fasciitis, S-114
nnanagennent,S-51
Femoral pulse
Episiotomy palpation, S-30
procedure, P-71
anaesthesia options, C-45, P-3 Fetal health and fetal distress
complications death of fetus, S-132
haematoma, P-74 heart rate
infections, P-7 4 fetal distress and, S-95
repair of, P-73 abruptio placentae and, S-19
artificial rupture of
External version membranes and, P-18
procedure, P-15 external version, monitoring
fetal heart rate and, P-15 requirements, P-15
normal labour and, C-57
Face presentation not heard, S-131
diagnosis, S-73 prolonged labour and, S-57
nnanagennent, S-77 sedative administration and,
S-131
False labour loss of movement, S-131
diagnosis, S-57 malpresentation or malposition,
nnanagennent, S-64 S-69
meconium-staining, S-96
Family members
emotional reactions of, C-7 Fetal skull landmarks, C-62
labour and childbirth, support
during, C-57 Fever
mortality, dealing with, C-9 diagnosis of
talking with, C-5 pregnancy and labour, S-100
postpartum, S-1 08
Index A-11
Fever (cont.) Haematoma

general management, S-99, broad ligament, S-20, P-96
S-107 cephalohaematoma, P-30
postoperative, C-55 episiotomy and, P-74
ruptured uterus involving, repair,
Fluids P-96
see also Infusion vaginal or perineal tears and,
enema, administration by, C-32 P-89
malaria and fluid managment, wound, S-113
S-55
subcutaneous, administration Haemoglobin
by, C-33 anaemia and, S-26
transfusion determinations, C-26
Foley catheter
induction of labour, P-25 Haemorrhage
see also Bleeding
Forceps delivery diagnosis
procedure, P-33 antepartum, S-17
anaesthesia options, C-44, P-3 postpartum, S-25
breech presentation with general management
entrapped head, P-41 antepartum, S-17
brow presentation, avoidance of postpartum, S-26
use in, S-76 cerebral, pregnancy-induced
complications hypertension and, S-48
rupture of uterus, P-35 coagulopathy and, S-19
tears, P-35 definition of, S-25
episiotomy to aid, P-35 delayed postpartum, S-33
failure, P-35 immediate postpartum, S-25
Piper forceps, P-41 IV infusions and, C-30
postpartum, prevention of, S-25,
Gastrointestinal function C-73
postoperative, C-53 replacement fluids, C-30
secondary postpartum, S-33
Glove and gown requirements, spinal anaesthesia, avoidance
C-18 of, P-11
Glucose solutions Haemostasis, C-51

replacement fluids, use as, C-30
Halothane
Grieving, C-10 inverted uterus, correction of,
P-92
Haematocrit
anaemia and, S-26
A-12 Index
Handwashing Hormones
general procedures, C-17 threatened abortion and, S-11
surgical preparation, C-49
Hyaline membrane disease in
Headache newboms, S-147
diagnosis of, S-38
Hypertension
Heart attack see also Blood pressure
see Cardiac arrest diagnosis of, S-36, S-38
nnanagennent
Heart disease chronic hypertension, S-49
heart failure and, S-128 eclampsia, S-43
ketamine, dangers of use of, pre-eclampsia, S-42, S-43
P-13 pregnancy-induced
hypertension, S-41
Heart failure antihypertensive drugs, S-46
diagnosis, S-126 complications, S-48
nnanagennent, S-127 diuretics, danger of use in, S-42
anaemia and, S-127
caesarean section, S-128, P-43 Hypodermic needles
heart disease and, S-128 sharps handling procedures, C-20
labour, management during,
S-128 Hypothermia
spinal anaesthesia, avoidance newborn, S-148
of, P-11
Hypovolaemia
Hepatitis see also Shock
diagnosis, S-1 01 spinal anaesthesia, avoidance of
see also Infection prevention use in, P-11
replacement fluids and, C-32
High blood pressure
see Blood pressure Hysterectomy
procedure, P-1 03
HIV postoperative care, P-108
see Infection prevention subtotal, P-1 04
rupture of membranes and total, P-107
danger of perinatal
transmission, P-17 Immunizations
tetanus, S-51
Hookworm
bleeding and, S-26
heart failure management, S-127
Index A-13
Induction and augmentation of Infusion (cont.)

labour phenytoin, S-52
procedure, P-17 replacement fluids, C-30
artificial rupture of membranes, colloid solutions, C-31
P-17 crystalloid solutions, C-30
augmentation, P-25 dextrose solutions, C-30, C-31,
cervix C-32, C-33
assessment of, P-18 glucose solutions, C-30
ripening, P-24 Ringer's lactate, C-21
Foley catheter, P-25 saline, normal, C-21, C-30
uterine rupture, oxytocin and, shock
P-19 management of, C-30, S-2 ·
plasma substitutes, danger of,
Infection C-21
breast, S-112 subcutaneous administration of
newborn sepsis, S-139 replacement fluids, C-33
sepsis after abortion, S-9 transfusion, alternatives to, C-30
urinary tract, S-101 venous cutdown, cannula
uterus, S-11 0, S-139 insertion, S-3
wound, S-113
Initial assessment, C-1
Infection prevention
general discussion, C-17 Injection
antibiotic prophylaxis, C-35 injection techniques, C-41, P-1
blood and blood products, C-24 tetanus, S-51
illV transmission, perinatal, P-17
hypertension complications, S-49 Instruments
labour, cleanliness during, C-58 surgery counts, C-51
surgical procedures generally,
C-47 Inverted uterus
diagnosis, S-27
Informational rights, C-5 management, S-33
procedure, correction of, P-91
Informed consent, C-47 anaesthesia options, C-45
hydrostatic, P-92
Infusion manual, P-91
procedure, C-21 surgical, P-92
blood transfusions compared, complications, P-94
C-23 post-procedure care, P-94
cannula insertion, C-21, S-3
fluid balance, S-55 Ketamine
heart failure and, S-128 procedure, P-13
maintenance fluid therapy, C-32
A·14 Index
Labour and childbirth Labour and childbirth (cont.)

see also Prolonged labour; pulse during, C-57
Malpresentation or pushing, S-67
malposition shoulder, delivery of, C-72
diagnosis, C-59 show, S-17
general management, C-57 stages of, C-60, C-70
acetone in urine, C-71 third stage, C-60, C-73
active management, third umbilical cord, checking, C-72
stage, C-73 unsatisfactory progress, S-57
augmentation of labour, P-25
bleeding during, S-17 Lacerations
blood pressure during, C-71 see Tears
caesarean, prior
oxytocin use after, P-21 Laparotomy
vaginal delivery after, S-93 anaesthesia options, C-45
cervix
dilatation, C-60 Lethargy
effacement, C-59, C-60 diagnosis of, S-126
childbirth positions, C-71 newborns, S-141, S-148
cord, checking, C-72
descent, assessment of, C-61 Lithotomy position, C-22
eclampsia, delivery mandates,
S-47 Local anaesthesia
head, delivery of, C-72 see Anaesthesia and analgesia
heart failure during, S-128
induction of labour, P-17 Loss of consciousness
labour positions, C-59 diagnosis of, S-38, S-39
maternal condition during, C-71 general management, S-35
multiple pregnancy, S-89 shock and, S-1
newborn care, initial, C-75
partograph Lovset's manoeuvre, P-38, P-39
assessment by, C-65
samples of, C-69, S-59, S-61, Maintenance fluid therapy, C-31
S-63
phases of, C-60 Malaria
placenta, C-73 diagnosis, S-39, S-103
placenta praevia, delivery general discussion, S-52, S-103
mandates, S-23 anaemia and, S-56, S-127
presentation and position, C-62 convulsions, S-54
previous caesarean fluid balance, S-55
oxytocin use after, P-21 hypoglycaemia, S-55
vaginal delivery after, S-93 drug resistant, S-104, S-105
progress, assessment of, C-64 severe/complicated, S-52
Index A·15
Malaria (cont.) Mauriceau Smellie Veit

uncomplicated, S-1 03 manoeuvre, P-40, P-41
Malformations Meconium
emotional considerations, C-12 aspiration, prevention of, S-143
general, S-147 breech presentation and, S-96
fetal distress and, S-96
Malposition or malpresentation thickness of, C-57, S-96
see also Breech presentation
and delivery Membranes
diagnosis, S-72, S-73, S-74, see also Rupture of membranes
S-75 artificial rupture, P-17
general management, S-69
breech presentation, S-74, S-79 Meningitis
brow presentation, S-73, S-76 diagnosis, S-39
caesarean section and, P-49
chin-anterior position, S-77 Metritis
chin-posterior position, S-77, diagnosis, S-108
S-78 management,S-110
compound presentation, S-74,
S-78 Migraine
external version, correction by, diagnosis, S-39
P-15
face presentation, S-73, S-77 Miscarriage
multiple pregnancy and, S-90 see Abortion
occiput positions, S-70, S-71,
S-72, S-75 Molar pregnancy
shoulder presentation, S-7 5, S-81 diagnosis, S-8
transverse lie, S-75, S-81 management, S-15
family planning after, S-16
Manual vacuum aspiration
procedure, P-65 Monitoring labour and childbirth
anaesthesia options, C-45 see Partograph monitoring
complications, P-68
dilatation and curettage Morbidity, dealing with
compared, P-61 maternal, C-9
post-procedure care, P-68 neonatal, C-10
Mastitis Multiple pregnancy

diagnosis, S-108 diagnosis, S-87
management, S-112 management, S-89
Necrotizing fasciitis, S-114

A-16 Index
Newborns Nutrition
general care principles, C-77 acetone in urine, C-71
asphyxia, S-147 dextrose, C-71
bacterial infections, S-147, labour, administration during,
S-148, S-149 C-58
breastfeeding, C-76, C-78
breathing check, C-73 Obstructed labour
breathing difficulty, S-141 diagnosis, S-57
breech delivery, care after, management, S-66
P-42 partograph, sample of, S-61
congenital syphilis, management,
S-150 Occiput positions
convulsions, S-149 diagnosis, S-70, S-71, S-72
cyanosis, S-146 management, occiput
hyaline membrane disease, S-147 posterior, S-75
hypothermia, S-148
initial care, C-75 Oedema
lethargy, S-148 see also Pulmonary oedema
low birth weight, S-147, S-149 diagnosis of, S-126
malformations, S-147 diuretics, danger of
oxygen administration, S-146, administration of, S-42
S-147 pre-eclampsia and, S-37, S-39
premature
preparation for, S-123 Operations
breathing difficulties, S-147 general principles, C-47
preterm rupture of membranes, see also Postoperative care
management after delivery, intra-operative care, C-48
S-149 pre-operative care, C-47
prolonged rupture of membranes,
management after delivery, Ovarian cysts
S-149 diagnosis, S-116,
resuscitation, S-142 management, S-117
separation from mother, C-76, appendicitis, confusion with,
C-78 S-115
sepsis, newborn, S-139 ultrasound and, S-14
syphilis, management, S-150
transferring, C-78 Overdistended uterus
ventilation, S-143 diagnosis, S-87
excess amniotic fluid, S-88
Not breathing large fetus, S-88
see Respiratory arrest multiple pregnancy, S-89
Index A-17
Oxygen Pelvis
newborn, difficulty breathing inadequate, determination of,
and, S-146, S-147 S-65
Pain Perineal tears

see Abdominal pain see Vaginal or perineal tears
Pain management Peritonitis

see also Anaesthesia and diagnosis, S-108
analgesia management, S-Ill
emotional support and pain appendicitis and, S-117
management, C-43
healing, pain relief and, C-46 Placenta
labour, C-58 see also Retained placenta
postoperative, C-46 accreta, S-32
surgical procedures, C-50 controlled cord traction delivery,
C-74
Pallor delivery, C-74
shock and, S-1 examination of, C-75
anaemia and, S-126 fragments, retained, S-32
manual removal
Paracervical block procedure, P-77
procedure, P-1 anaesthesia options, C-45, P-3,
P-11
Partograph complications, P-79
general use, C-65 inverted uterus and, P-91
samples post-procedure care, P-79
contractions, inadequate, S-63 membrane tears, C-75
normal labour and childbirth, removal at caesarean section,
C-69 P-45
obstructed labour, S-61 retained, S-27, S-31
prolonged labour, S-59
Placenta praevia
Pelvic abscess diagnosis, S-18
diagnosis, S-1 08 managment, S-21
management, S-11 0 caesarean section and, P-49
colpotomy, P-70
culdocentesis, P-69 Plasma transfusions
coagulopathy and, S-20
Pelvic inflammatory disease infection risks, C-24
ectopic pregnancy, confusion replacement fluid use, C-31
with, S-7
A-18 Index
Pneumonia Premature labour and childbirth

diagnosis, S-126 see Preterm labour
management, S-129
Presentation
Position see also Malposition or
see Malpresentation or malpresentation
malposition normal presentation, C-62
Postoperative care Preterm labour

bladder, C-54 diagnosis, S-120
bleeding, internal, monitoring management, S-122
for, C-53 newborn
fever, C-55 preterm, care of, S-147, S-149
gastrointestinal function, C-53 bacterial infections in, S-147
initial, C-52 hyaline membrane disease,
pain relief and healing, C-46 S-147
suture removal, C-55 low birth weight, S-147, S-149
wound, C-54 rupture of membranes, preterm,
S-135
Postpartum care
bleeding, S-25 Privacy rights, C-5
breast engorgement, S-111
breast infections, S-112 Prolapsed cord
caesarean section, postoperative management, S-97
care, P-50 breech presentation and, S-80
depression, C-13 compound presentation and, S-78
fever, S-107 delivery, checking during, C-72
haemorrhage, S-25 overdistended uterus and, S-88
psychosis, C-14
symphysiotomy, care after, P-56 Prolonged labour
see also Induction and
Postpartum haemorrhage augmentation of labour
see also Bleeding; Haemorrhage diagnosis, S-57
generalrnanagernent,S-25 management
latent phase, S-64
Pre-eclampsia active phase, S-65
see Eclampsia and pre-eclampsia expulsive phase, S-67
cephalopelvic disproportion,
diagnosis, S-136 obstruction, S-66
rnanagment,S-136 partograph, samples of S-59,
newborn care and, S-149 S-61, S-63
uterine activity, inadequate, S-66
Index A-19
Proteinuria Resuscitation
diagnosis of, S-37, S-38 newborn, S-142
measurement of, S-37
pre-eclampsia and, S-37, S-39 Retained placenta
diagnosis, S-27
Provider linkages, C-79 unanageunent, S-31
cord traction delivery, S-31
Psychosis ergometrine, danger of use of,
ketamine, dangers of use of, S-31
P-13 fragments, retained, S-32
postpartum, emotional
considerations, C-14 Rights of women, C-5
Pubic hair Rupture of membranes

shaving, C-48 artificial rupture, P-17
HIV prevalence and, P-17
Pudendal block normal labour, C-57
procedure, P-3 prelabour, S-135
Pulmonary oedema Ruptured uterus

diagnosis, S-38 diagnosis, S-18
pre-eclampsia and, S-44 unanageunent, S-20
repair, P-95
Pulse caesarean section after, S-94
shock and weak pulse rate, S-1 forceps delivery, P-35
impending rupture, S-94
Pyelonephritis induction of labour and danger
see Acute pyelonephritis of, P-19
oxytocin administration and
Rales danger of, P-19
diagnosis of, S-126 pregnancy risks after, P-98
pulmonary oedema, scars causing, S-93
pre-eclampsia and, S-44 shoulder dystocia and, S-84
symphysiotomy to avoid, P-53
Rapid initial assessment, C-1 vaginal delivery after, S-93
Referral patterns, C-80 Salpingectomy or salpingostomy

procedure, P-109
Respiratory arrest family planning counselling
see also Breathing and after, P-111
breathing difficulty pregnancy risks after, P-111
anaesthesia reactions, C-42
A-20 Index
Sharps Suture
handling, C-20, C-51 removal, C-55
needle-stick injury, pudendal selection, C-52
block and, P-5
surgery counts, C-51 Symphysiotomy
procedure, P-53
Shock anaesthesia options, C-45
diagnosis, S-1 brow presentation, avoidance
management, S-1 of symphysiotomy in, S-76
anaphylactic shock, C-28 complications, P-56
causation, S-4 post-procedure care, P-56
emergency response, C-15 risks, P-53
IV infusions, C-21, C-30 ruptured uterus, avoidance of,
replacement fluids, C-30 P-53
septic, blood trasfusion and, vacuum extraction and, P-30,
C-29 P-53
transfusion caused, C-28
transfusion requirements, C-23 Syphilis
congenital, S-141
Shoulder dystocia death of fetus, S-132
diagnosis, S-83 management in newborns, S-150
managment, S-83
brachial plexus injury and, S-84 Tears
see also Cervical tears; Vaginal
Shoulder presentation or perineal tears
diagnosis, S-75 bladder, P-97
management, S-81 bleeding caused by, S-31
placenta, examination for, C-75
Spinal anaesthesia
procedure, P-11 Tetanus
diagnosis, S-38
Stillbirth management, S-50, S-51
emotional considerations, C-1 0
Thrombosis
Supine hypotension syndrome, see Deep vein thrombosis
C-48
Tocolysis and tocolytic agents
Support companion conditions of use, S-122
see Family members precautions for use, S-123
threatened abortion and, S-11
Surgery
see Operations Training, C-80
Index A-21
Transfusion Umbilical
see also Blood and blood see Cord; Prolapsed cord
products
general principles, C-25 Unconsciousness
autotransfusion, C-26, S-14 see Loss of consciousness
coagulopathy management, S-19
haemoglobin value and, C-26 Unsatisfactory progress of labour
infection risks, C-24 see Prolonged labour
monitoring, C-27
reactions Ureter
anaphylactic shock, C-28 protection during surgical
bronchospasm, C-28 procedures, P-96, P-99, P-104
monitoring for, C-27
replacement fluid alternatives, Urinary tract infections
C-30 diagnosis of, S-100, S-101
nnanagennent
Transverse lie acute pyelonephritis, S-1 02
diagnosis, S-75 cystitis, S-101
nnanagennent, S-81 false labour and, S-64
caesarean section and, P-49
external version, P-15 Urine
internal podalic version, S-90 proteinuria and pre-eclampsia,
S-37, S-39
Trauma scanty output
shock management, S-4 magnesium sulfate
administration and, S-45
Tuballigation malaria and, S-55
caesarean section and, P-51 shock and, S-1
ruptured uterus repair and, P-96 testing
proteinuria, S-37
Tuberculosis urinary tract infection, S-101
pneumonia and, S-129
Uterine and utero-ovarian artery
Typhoid ligation
diagnosis, S-109 procedure, P-99
Ultrasound Uterine atony

confirmation of diagnosis see Atonic uterus
ectopic pregnancy, S-14
fetal death, S-132 Uterine inversion
ovarian cyst, S-14 see Inverted uterus
overdistended uterus, S-87
placenta praevia, S-22
A-22 Index
Uterus Vaginal examination (cont.)

see also Atonic uterus; Inverted descent assessment by, C-61
uterus; Ruptured uterus placenta praevia and, S-21
appendicitis and gravid uterus, progress of labour, assessment
S-119 of, C-64
artery ligation, P-99
bimanual compression of, S-29 Vaginal or perineal tears
caesarean section, closing, P-47 repair, P-83
dilatation and curettage, P-61 anaesthesia options, C-45, P-11
inadequate uterine activity and anal sphincter tears
prolonged labour, S-66 detection, P-83
manual vacuum aspiration, P-65 neglected cases, P-89
massage after placenta delivery, repair, P-86
C-75 bleeding caused by, S-31
overdistended, S-87 complications, P-89
packing, S-30 degrees of tears, P-83
scarred uterus and vaginal forceps delivery causing, P-35
delivery, S-93 haematoma, P-89
post-procedure care, P-88
Vacuum aspiration ruptured uterus involving,
see Manual vacuum aspiration repair, P-96
Vacuum extraction Vaginitis

procedure, P-27 diagnosis, S-136
anaesthesia options, C-45 Foley catheter, dangers of use
brow presentation, avoidance of of, P-25
use in, S-76
complications Ventilation
cephalohaematoma, P-30 newboms, S-143
tears, P-31
episiotomy to aid, P-28 Vision
face presentation, avoidance of see Blurred vision
use in, S-78
failure, P-30 Vomiting
preterm labour, avoidance of diagnosis of, S-8, S-9, S-39,
use in, S-123 S-100,S-108,S-116
symphysiotomy and, P-30, P-53 anaesthesia administration and,
C-46
Vaginal bleeding shock management, S-2
see Bleeding
Waste disposal, C-20
Vaginal examination
bleeding danger, C-1, S-17, S-21
Index A-23
Water, breaking
see Prelabour rupture of
membranes
Wounds
infections of, S-113
surgical wound care, C-54

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WHO/RHR/00.

Integrated Management Of Pregnancy And Childbirth

WHO UNFPA UNICEF World Bank

Department of Reproductive Health and Research

~ Department of Reproductive Health and Research

Managing complications in pregnancy and childbirth : a guide for midwives

At head of title: Integrated Management of Pregnancy and Childbirth.

l.Pregnancy complications - diagnosis 2.Pregnancy complications -

ISBN 92 4 154587 9 (NLM classification: WQ 240)

© World Health Organization 2003

The mention of specific companies or of certain manufacturers' products does not

Printed & bound in India

Major contributors: Matthews Mathai

Contributors: Fredrik Broekhuizen

Editing: Melissa McCormick

Editing Assistance: Ann Blouse

Artist: Mary J ane Orley

Cover design: Maire Nf Mhearain

Layout: Deborah Brigade

The special contribution of George Povey, whose original work inspired

The financial support towards the preparation and production of this

WHO gratefully acknowledges the technical and editorial assistance

Preface to the second printing iii

SECTION 1: CLINICAL PRINCIPLES

Rapid initial assessment C-1

Prelabour rupture of membranes S-135

Paracervical block P-1

Essential drugs for managing complications in pregnancy and

The manual, Managing Complications in Pregnancy and Childbirth,

In support of the Safe Motherhood Initiative, the WHO Making

A woman presenting with a life-threatening obstetric complication is in

Section 1 outlines the clinical principles of managing complications in

post-procedure care for ketamine anaesthesia). Clear guidance is

AIDS Acquired immunodeficiency syndrome

Normal labour and childbirth C-57 Multiple pregnancy S-87

TABLE C-1 Rapid initial assessment"

TABLE C-1 Cont. Rapid initial assessment

Assess Danger Signs Consider

IMPLEMENTING A RAPID INITIAL ASSESSMENT SCHEME

EMOTIONAL AND PSYCHOLOGICAL REACTIONS

GENERAL PRINCIPLES OF COMMUNICATION AND SUPPORT

AT THE TIME OF THE EVENT

AFTER THE EVENT

Repeat information several times and give written information, if

MATERNAL MORTALITY AND MORBIDITY

AT THE TIME OF THE EVENT

AFTER THE EVENT

SEVERE MATERNAL MORBIDITY

AT THE TIME OF THE EVENT

AFTER THE EVENT

NEONATAL MORTALITY OR MORBIDITY·

INTRAUTERINE DEATH OR STILLBIRTH

AT THE TIME OF THE EVENT

Prepare the parents for the possibly disturbing or unexpected

AFTER THE EVENT

AT THE TIME OF THE EVENT

AFTER THE EVENT