SALSO
APH (causes: PA,PP, VP indeterminate APH, local causes)
-Recognition of hemorrhage >find cause based on scenario, assessment of blood loss by visual
estimation of blood loss (pictogram), hypovolemic shock classification and obs shock index (HR/SBP)
-Communication for help based on severity :
minor h’rage no shock- obs reg, midwife, HO, anaest trainee
major h’rage with shock- obstetrician, anaes, midwife, HO, blood bank, ACTIVATE RED ALERT >
consultant must be present
-Resuscitation
1.regularly assess Response, Airway (patent, dentures, yonkeur suction if any secretion), Breathing(
supplemental oxygen 15L/min via facemask), Circulation (set 2 large bore Iv cannula)
2.place woman flat
3, warm the woman
4.take blood : FBC, Coagulation profile, GXM 4pints Packed cell, BUSE CR
5.fluid resuscitation with crystalloid (blood loss: cystalloid 1:3), then colloid (2:3) if still hypovolemic
transfuse packed cell (safe O blood group)
6.Massive transfusion protocol activated in case of massive haemorrhage (red cell: FFP :Platelet)
1:1:1 (MTP definition)
7.monitor vital signs every 15mins until stabilized
8.reassessment of blood loss and shock index periodically if there is ongoing loss
9. monitor fetal wellbeing (CTG)
10.after delivery watch out for PPH
Common causes of APH
-investigations: transabdominal US, transvaginal ultrasound – TRO PP, assess fetal lie and viability
-speculum examination
-Rule out PP then do VE
Placenta praevia > 16weeks All same + CBD
Repeat US scans at 32 and ##NO VE
36weeks Prev bleeding with PP > hospitalised until delivery
-If significant bleeding + >26week: give IM dexamethasone
-PP bleed in labour <37 weeks > tocolysis to complete
corticosteroids
-Any women with PP admit 36 weeks (aim delivery 36-37weeks) >
ensure weekly GSH available and HB optimised
Definitive: LSCS
## IOL contraindicated
Placenta abruptio 1.recognise severity (3methods)
2.assess and stabilise the woman
-Assess woman (vitals, FHR-CTG)
Add CBD and Analgesia (management according to stepladder)
3.assess fetal viability
4.dx APH 2 PA
***during monitoring watch out DIVC** >abruptio + IUD
5.Delivery plan
Vaginal delivery: favourable cervix, IUD, live baby with reactive
CTG
C section: unfavourable cervix, fetal compromise, other obs
indication AND also (fetal distress, slow progress, active bleeding)
###TOCOLYSIS contraindicated in placenta abruption
District resus + ARM (if cervix favourable) > refer to tertiary/ with
sp
Vasa praevia Mx: immediate LSCS
PPH
1.Call for help – Obs, anesthesia ,blood bank ,midwife, HO
2.Initial action
-ABC including vital signs (BP,PR)
-2 large bore cannulas (14-16 Gauge)
-take blood : FBC, PT/APTT, GXM 4 unit of blood
-Set up IV drip
3.resuscitation: crystalloid/colloid/ blood (depend on EBL)
4.Tone: massage uterus (to assess tone), insert CBD allow effective uterine contraction, monitoring
urine output
MX:
-oxytocin (pitocin): IM 10 units stat- only once/ IV 5 units stat > dose x2 total dose 10units
-syntometrine -IM 1 ampoule
-ergometrine- IM 0.5mg STAT
-carboprost (haemabate)- IM 250mg (15mins apart) > max 8 doses
**IV oxytocin infusion (40unit/ pint) run at 125ml/hr -to maintain contraction
-Uterine tamponade with Bakri balloon
-if fail > surgical interventions (B lynch brace sutures, uterine artery ligation, internal iliac artery
ligation)
-hysterectomy or Uterine artery embolization
-do bimanual compression
-anti shock garment
<3hrs delivery >
###dont do vaginal packing > cause hematometra
5.Tissue: check placenta /membranous** (retained placenta)
6.Trauma: check vagina/cervix
7.Thrombosis: blood investigation results ,correct coaguopathy
8.close monitoring post delivery, admit ICU/HDU
Shoulder dystocia -HELPERRR
H Help Call for help (paeds, obs, staff nurse, ho)
E Episiotomy Perform adequate/generous episiotomy (to do manouver)
L Legs McRobert’s manourvre -hyperflexion hip, abduct hip, flex
knee
-increase inlet diameter
-straighten lumbar lordosis
-remove sacral promontory
-push post shoulder over sacral promontory
P Pressure Suprapubic pressure: to disimpact the shoulder and push
to oblique position
E Enter Wood’s screw manouvre (1 hand post aspect of ant
shoulder and ant aspect of post shoulder) : to change to
oblique position > 180’
R Remove Remove posterior arm, flex forearm at elbow of forearm
extended, delivery of arm by sweeping across face and
chest
R Roll Roll the patient to her hands and knees- remove posterior
arm (using gravity)
R Repeat Repeat from L (Mc Roberts manouvre)
Others:
-Symphysiotomy
-Clavicular #
-Zavanelli maneuver : push head inside and C sec
Post event
-watch PPH
-extended perineal tear
-baby examined by paediatric team >tro fracture, brachial plexus injury
-debriefing to parents of intrapartum event
-documentation
Cord prolapse
-initiate RED ALERT
-Call for help (senior obs MO/registrar, paeds MO for resus, anaest team, senior midwife)
-confirm the viability of fetus via scan or daptone (don’t palpate cord for pulsation to determine
viability, absence of pulsation in prolapsed cord is unreliable)
-arrange for immediate delivery :
Os not fully dilated/ delivery not imminent: delivery via category 1 C section
Os fully dilated and delivery imminent: trial of vaginal delivery w/ wo instrumental delivery
-if cord outside, replace the cord within vagina if possible ; cover with warm/wet towel, minimise
handling cord > prevent spasm
- elevate presenting part to avoid cord compression : any one
1.elevate woman’s buttock using pillow
2.maintain hand inside vagina and elevate presenting part with fingers. Do not attempt to push the
cord away as any manipulation of the cord may cause vasospasm
3.fill maternal bladder with 500ml sterile water/ saline via Foley’s catheter
-consider tocolytics > to reduce established uterine contraction (SC or IM terbutaline 250microgram)
Mx: emergency C section
Retained placenta
-undelivered placenta via CCT within 30mins of delivery of fetus
-ensure before making dx: CBD, syntometrine, sufficient time
-snapping of cord not equivalent to retained placenta
Prepare for MRP
1. inform MO SP
2.Inform/counsel regarding MRP
3.Set 2 large bore IV line (16G or 18G)
4.Group and cross match 2units of packed cells
5.Monitor BP and HR every 15mins while awaiting OT call and during procedure
6.start iv Pitocin 40units in 1pint NS 125ml/H
7.resus woman if shock
#mrp done in OT with anaes
#active bleeding > consider mrp in labour ward under sedation
Procedure
1 aseptic teachnique, sterile gown, long gloves
2 stop Pitocin once in OT
3 prophylactic antibiotic: stat dose IV Cefuroxime 1.5g + IV Metronidazole 500mg
4 hold the cord in your left hand(non dominant)
5 follow cord with your right hand all the way into the uterus until base of placenta is identified
6 separate placenta from uterus with your fingers in see saw motion
7 keep your fingers pointing away from uterine wall and towards placenta
8 continue separation until entire placenta has been separated
9 remove placenta in one bulk, use your left hand to guard uterus to prevent uterine inversion
10 check placenta and membranes for completeness
11 perform digital exploration of ut cavity if there is any suspicion of retained POC
12 once uterus cavity emptied, iv Pitocin 5 units slow blous can be given followed by Pitocin 40units
infusion (dr soe: 24hrs)
13 check perineum and cervix for tears and repair if needed
14 watch out for PPH and manage
Post procedure
1 proper documentation: placenta and membranes, any assoc tears and repair done, estimated
blood loss, any blood transfusion given
2 continue IV Pitocin infusion for 4 hours
3 IV fluids and strict fluid balance monitoring
4 adequate analgesia
5 check uterus regularly to ensure it is well contracted
6 pad charting and vital sign monitoring at least 2hrly
7 repeat FBC and coagulation profile if PPH
8 prior to discharge, ensure:
-woman debriefed on intrapartum events and procedure performed
-woman able to void normally
-woman advised regarding antibiotics and s/s of endometritis.
Hypertension disorders of pregnancy
General principles of management of severe hypertension:
1.Control of blood pressure (>160/110mmHg)
-oral nifedipine (in case no parenteral labetolol) >180 (Iv labetolol)
-if Labetolol CI (asthma, CCF, heart block) use Iv Hydralazine
-if resistant IV GTN
Target: 140-159/90-109 mmHg > to avoid maternal hypertension , compromising uteroplacenta
perfusion
-close fetal monitoring >28weeks continuous CTG, <28weeks 5-10minutes daptone
Oral
T.nifedipine 10mg > max dose 2 (30minutes gap)
Side effect: maternal tachycardia, headache
Parenteral
Labetolol
Concerntration 1amp =25mg (5ml) (5mg/ml), 1ml =5mg no need dilution
Bolus dose 1st dose= 1amp 25mg in 2 minutes
2nd dose=2amp 50mg in 2 minutes (30minutes gap)
3rd dose=2amp 50mg in 2 minutes (30minutes gap) >180 sbp*
specialist
Infusion dose
preparation No need dilution
Withdraw 10vials (250mg) in 50cc syringe
Titration **titration done every 30minutes
Starting dose 20mg/hr (4ml/hr) > 40mg/hr > 80mg/hr> 160mg/hr
(32ml/hr)* consider iv hydralazine after max rate
CI and SE Bronchial asthma, heart block , CCF
SE: maternal brady, neonatal brady
Hydralazine
Concerntration 1amp =1ml (20mg/ml)
Withdraw 1 amp + 19ml NS = 20mg/20ml = 1mg/ml
Bolus dose 1st dose= 5mg in 2 minutes
2nd dose=5mg in 2 minutes (30minutes gap)
3rd dose =5mg in 2 minutes (30minutes gap) >180 sbp* specialist
Infusion dose
preparation Withdraw 2 amp + 38ml NS =40mg/ml =1mg/ml
Titration Starting dose 1ml/hr (1ml/hr)
Titrate up every 30mins 1ml/hr ; max 10ml/hr
Target: 140-159/ 90-109, maintain dose if target bp achieved, if
bp< then titrate down
CI and SE CI: maternal tachy
SE: maternal hypotension, headache, dizziness
IV Glyceryl trinitrate (bp uncontrolled)
Concentration 1ampoule= 10ml (50mg/10ml)
Preparation Infusion pump: 50mg (10ml) +240 NS/DS 5% = 200microgram
Syringe pump: 10mg (2ml) + 48ml NS/DS 5% =200microgram
Infusion Start dose: 1.5-3ml/hr
Titrate: 1.5-3ml/hr every 5-10mins ; max dose:200microgram
(60ml/hr) target:140-150/90-109
Monitoring Bp monitor 5-10mins -detect mat hypotension
Continuous CTG
2.Prevent and/or control of eclampsia
IV MgSO4
Loading dose Maintenance dose
Dose 4g IP=1g/hr SP=1g/hr
Concentration 1amp=2.47g/5ml 1amp=2.47g/5ml 1amp=2.47g/5ml
Preparation Withdraw 8ml (4g) of 10amp =50ml MgSO4 + 2amp (5g/10ml) of
MgSO4 + NS 12ml 450ml NS MgSO4 + 40ml NS =
=20ml 5g/50ml
Administration 4g slow bolus Infusion rate= 21ml/hr Infusion rate= 10ml/hr
15-20minues (1g/hr) (1g/hr)
Continue infusion of Continue infusion of
MgSO4 for 24hrs after MgSO4 for 24hrs after
delivery or last seizure delivery or last seizure
(whichever occur later) (whichever occur later)
IM MgSO4
Loading dose Maintenance dose
Dose 10g (5g each buttock) 5g every 4hrs
Concentration 1amp=2.47g/5ml 1amp=2.47g/5ml
Preparation 2 amp + 1ml LA 2amp + 1ml LA
Administration Deep im into each buttock Deep im injection alternate buttock every
4hrly until 24hrs
**monitor mg level
3.monitor fetal and mother
4.fluid management
-2L /day
-strict I/O charting
-fluid challenge if indicated
-fluid restriction if APO > ICU/HDU [diuretic only given APO]
5.delivery
37 and more -delivery indicated , MOD – depend on F/M condition
34-36+6 – sp make decision, antenatal corticosteroids +/-, if urgent no need corticosteroid
<34 – sp decision, antenatal corticosteroid a must
Eclampsia
1.call for HELP (initiate red alert)
2. resuscitation
-ictal: left lateral and o2 supplementation
-post ictal: assess response, ABC > maternal cardiorespiratory resuscitation
3 secure at least 2 large IV lines, take blood for investigation (FBC. BUSE CR, LFT, Serum uric acid,
LDH, Coagulation profile)
4 Abort seizure with MgSO4
5 If woman develop another seizure during or after loading dose, administer another 2-4g IV MgSO4
6 Monitor in HDU ICU
7 Start parenteral anti hypertensive if >160/110
8 monitoring according to protocol
9 total fluid 2L per day
10 monitor fetus
11 plan for delivery after patient is stabilised
12 if eclampsia recurs, to refer anaestist for intubation and cerebral resus in ICU
Diazepam regime
-if no MgSO4
-despite 2nd loading dose, while waiting for for anaes
-give slow bolus IV diazepam 10mg 5mins, repeat dose
HELLP Syndrome
-severe pre eclampsia or eclampsia
-hemolysis
-hepatic dysfunction (LDH, Indirect bilirubin, AST)
-low plt
Management
1 assessment and evaluation of patient
FBC, Coagulation profile
PBF- histiocytes
BUSE CR
Serum uric acid
LFT
Urine dipstick , UPCR
2 Assessment of fetus- US /CTG
3 Control BP
4 Prevent seizure -use MgSO4
5 Consider platelet - <50 , or symptomatic and correction of coagulopathy (FPP, cryoprecipitate) if pt
planned for operative delivery
6 plan for delivery -timing and mode
Vaginal breech
-conduct vaginal breech delivery only if birth imminent of baby
-ensure continuous FH monitoring
-delivery conducted by most experienced personnel available
-another MO/paed MO for neonatal resus
-deliver in lithotomy position with mother’s nuttock at end of bed
-drain bladder before commencing active 2nd stage
-follow basic principles of Hands off teachnique
1.hands off technique – allow breech descent via active pushing by mother, active pushing only when
breech has descended to pelvic floor and visible
2.wait until anus is visible over fourchette, then episiotomy > protect fetal using left hand
3.do not allow sacrum to turn posterior (sacrum shld be either Left or Right of mother)
4.insert 2 finger anterior to the sacrum as mother push baby out
Delivery of legs
5. keep sacrum anterior, extended leg > pinard manouver (apply pressure on popliteal fossa to flex
knee and lateral rotation of thigh. Grasp fetal foot and deliver leg)
6. deliver anterior leg first, rotate, deliver post leg
7. if cord loose > don’t manipulate > vasospasm
Holding baby
8. wrap baby with warm clean towel > prevent slipping and keep warm
9.hold
Thumb- sacrum
Index finger- ASIS
Last 3 finger -thigh
#Dont hold chest and abdomen
Delivery of fetal arms
10.once scapula visible, deliver arms
11.if arm x deliver spontaneously > sweep 2 fingers over the shoulder until reach elbow and follow
ROM of shoulder
If extended arm
12. Lovset maneuver – hold hip and apply downwards traction while rotating baby 180’ to bring post
arm to ant arm, deliver ant arm first. ***When turning > keep back facing upwards
13.if baby body cannot be turned > deliver post shoulder first > lift baby upwards and laterally >
deliver posterior arm
14.lay baby back down and the ant shoulder now deliver as usual
Delivery of fetal head
15.Mauriceau – smellie- veit method (MSV)
Index and middle finger on maxillary prominence
Don’t insert into mouth
Another hand use middle finger to press occiput
Both hands used in attempt to flex the baby head
Deliver in direction of birth canal
16. Burns marshall manouvre
-hold baby feet with 1 hand
-support baby body with other hand
-avoid over extension of spine/back
-somersault baby over mother back
-assistant support perineum
Piper forcep
-preterm breech > head entrapment > duhrssen’s incision > cervical incision 2 6 10 o clock
-baby head should be delivered of buttocks or within 3mins from delivery of umbilicus
Post delivery
17.active 3rd stage management
18. watch out for pph
19 check for cervical tears/ perineal trauma
20 counsel mother regarding intrapartum events > and any complication that may occur
21.document all procedures
CPR in pregnant woman
-causes of cardiopulmonary collapse :
4H- hypovolemia, hypoxia, hypothermia, hypo/hyper K, H+
4T- thromboembolism (cardio , pulmonary) , toxicity, tension pneumothorax, cardiac tamponade
Flow chart
D- danger (personal ppe)
R- assess response
With response
-left lateral
-assess ABC
-shout for help
-find maternal cause of collapse
-assess regularly
No response
-shout for help (senior personel > obs, mo, nurse, MA)
-A: open airway, head tilt chin lift, jaw thrust, clear airway
-B: check breathing, assess breathing by looking at chest, neck and face for 5 to 10s
A)No breathing:
CPR
Woman tilt to left
Start chest compression >30 to 2 breath
Rate 100/min
Keep arm straight > depress sternum 5cm
Continue 5cycles > 30:2
Prepare defibrillator, intubation , pharmacologic agent
Resuscitative hysterotomy
-no ROSC after 4mins after CPR
->20 weeks POG
-relieve aortocaval compression
-to be performed at the place where resus take place
B) Presence of normal breathing
-left lateral
-assess ABC
-shout for help
-find maternal cause of collapse
-assess regularly
