The methods

1. Fetal movement chart
2. Non-stress test/Cardiography
3. Modified Bishop’s Score (Non stress Test + Amniotic Fluid Index-AFI)

 Indications

High risk pregnancies such as seen with

-Hypertension

-Post dates 

-Diabetes mellitus

-Bad obstetric history e.g. recurrent and unexplained still-births

-Intrauterine Growth Restriction

 Fetal kick chart

A daily count of perceived fetal movements from about 30 weeks gestation is a simple and inexpensive routine screening method for monitoring fetal wellbeing. A warning signal is when there are fewer than 10 movements in a 12 hour period.

Method

Ask women to record fetal kicks over a two hour period in the morning. If she can feel three or more movements then she repeats again the same the next day. If however she feels less than three or absent fetal movements, she repeats the recording of fetal kicks for a two hour period in the evening. If they are still reduced she is advised to come to hospital first thing in the morning for a Non Stress Test.

Note

-Reduced fetal movements often but not invariably precedes Intrauterine Fetal Death, in some cases, by several days 

-Non-reassuring fetal movement assessment (e.g. <10 kicks in 12 hrs) means further fetal assessment is needed e.g. Non StressTest

-Mother lies on her lateral side and counts distinct Fetal Movements, 2 hours in the morning and 2 hours in the evening. 

-It is reassuring if fetal movements are greater or equal to previously established baseline count.

-False positive rate is high and therefore we do a Non Stress Test whenever a woman complains of reduced fetal movements.

Cardiotocography (CTG)

We do a non-stress test (NST) loosely termed CTG, because we record fetal heart rate pattern in response to fetal movements and not to a uterine contraction. In high risk pregnancies, where there is concern about babies growth and/ or wellbeing you should request a weekly or even twice weekly NST from about 30 weeks. There may be a midwife to do this but because of shortage it may mean that the SRMO/SHO may need to do it. Therefore be familiar with how it is performed. Before doing a NST, the patient should be in lateral tilt and should not smoke.

Four parameters to look at when reading a NST:

-Baseline fetal heart rate- this should be 110-160 per min

-Baseline variability(by how much does the fetal heart rate vary above and below this baseline)- Normally >5

-Are there any accelerations in response to fetal movements? An acceptable acceleration should go up by 15 beats and should last for 15 secs from start to finish.

-Are there any decelerations? Beware of loss of contact with fetal movements.

Interpretation

1.REACTIVE - normal baseline, normal baseline variability, no decelerations and at least 2 accelerations in 20 min - good sign

2.Non-reactive trace - normal baseline, normal baseline variability, no acceleration and no decelerations- carry on with trace for longer period or stimulate baby by manipulation and repeat.

3. Flat trace - normal baseline, baseline variability less than 5, no accelerations and no decelerations - by itself this may not mean hypoxia but if associated with any other abnormality, it is a bad sign.

4. Abnormal trace - any of above with decelerations. Whenever you see decelerations please check that the woman was not lying on her back during the NST. If in doubt repeat with woman on her side.

If you request a NST, it is the duty of the SRMO/SHO to ensure that every effort is made to read it and relay information to her. If there are any problems, please contact Registrar for firm or the Registrar on call for the day in LW to discuss further management. 

Precautions with NST

-A NST of a pre-term non-compromised fetus is frequently non-reactive

-At 24-28 week EGA: up to 50% NSTs may not be reactive

-By 28-32 week EGA: 15% of NSTs are non-reactive.

-Variable decelerations: may be seen in up to 50% of NSTs; if non-repetitive  and brief (<30sec)à don’t indicate fetal compromise and there’s no need for obstetric intervention.

• Repetitive deceleration (3 in 20 minutes): increased risk for Caeserian section 
• If Fetal Heart Rate deceleration is 60 seconds: even higher risk for Caeserian section 

Modified Biophysical Profile (MPP) Rationale

• During 2^nd and 3rd trimester amniotic fluid reflects fetal urine production. If there’s placental insufficiency/dysfunction, there is reduced renal perfusion resulting in oligohydramnios
• Amniotic fluid volume is used to evaluate long-term placental function, and the NST is a short-term indicator of fetal acid base status. 

Parameters assessed for the Modified BPP:

• Amniotic Fluid Index  
• Non stress test

A modified BPP is considered normal if

• AFI > 5 
• NST reactive

It is considered abnormal if either 

• AFI ≤ 5 or
• NST non - reactive

Timing/When to initiate Antenatal Fetal Monitoring(AFM)

Starting of AFM is dependent on: 

-Prognosis for neonatal survival

-Severity of maternal condition

-Risk of IUFD

There is always a potential for iatrogenic pre-maturity due to false-positive test results. It is usually recommended to start AFM from viability (24-26weeks) for most high-risk patients.

Note

-Frequency of AFM is a function of clinical judgment and several factors.

Response to an abnormal AFM test should always be tailored to the clinical situation

Bleeding from the genital tract occurring at any time after fetal viability, greater or equal to 24 weeks gestation, but before the birth of the child.

causes:

1. Placenta praevia 

Bleeding from separation of a placenta situated in the lower segment of the uterus.

• Risk factors include:  Multiparity, multiple pregnancy and previous caesarean section.

• Clinically: Woman will present with painless fresh vaginal bleeding often during rest or sleep.

• Bleeding may have been precipitated by intercourse.

• Fetal movements are usually still present.

• Degree of shock corresponds to amount of vaginal blood loss

• the uterus is soft, non-tender and the fetal parts are easily palpable.

• The presenting part is high or there may be malpresentation.

• Fetal heart is usually present.

2. Placental abruption

Bleeding from premature separation of a normally situated placenta.

Risk factors include:

• Hypertensio
• reduction in uterine size after rupture of membranes with polyhydramnios
• rarely direct trauma to abdomen
• Clinically:
• Women will present with varying amounts of blood loss and severe continuous abdominal pain.
• The degree of shock (pallor, tachycardia, hypotension etc.) may be out of proportion to vaginal blood loss.
• The uterus may be larger than dates and the tenderness is localised or generalized over the abdomen, in which case the uterus feels hard and tender.
• With a large bleed, the foetus is usually dead. With minor bleeds, the  foetus may show signs of distress.

3.Indeterminate haemorrhage or APH of unknown cause  Bleeding from slight separation of a normally situated placenta.

Clinically: 

• Bleeding is mild to moderate with slight pain over abdomen.
• There is no evidence of shock and there may be localised abdominal tenderness.
• Fetal heart rate is usually normal.
•  

3.Bleeding from local lesion of the genital tract

These include cervical erosions, trichomonas vaginitis, cervical polyps, cervical cancer etc. Management

1.History

• enquire specifically about the amount of bleeding (tablespoons, cupfuls)
• Were there any warning bleeds before this one
• Is there any associated pai
• Was there any trauma including intercourse
• Is the baby movin
• Is she having labour pains

Examination:

• Assess general condition,features of shock
• Assess degree of blood loss
• try and diagnose cause of the bleeding.
• Abdominal examination must be gentle, feeling for tenderness, consistency, fetal parts, malpresentation and listening for fetal heart. DO NOT ATTEMPT TO DO A DIGITAL VAGINAL EXAMINATION AS THIS MAY CAUSE MASSIVE HAEMORRHAGE IF PLACENTA IS LOW LYING.
• If the bleeding is severe and life threatening.
• Resuscitate immediately: 1-2 intravenous lines using at least 16G cannula and run Ringers Lactate or normal saline fast to bring blood pressure up.
• If there is an experienced anaesthetist put up CVP line to avoid fluid overload
• Give 4 units of fresh plasma if bed side clotting prolonged (>10 minutes)
• Give blood (packed cells) as required.
• Crude bed side clotting time.
• Take blood for cross match haemoglobin and platelet count.
• Can use 1-2 bottles of Haemaccel while waiting for blood.
• Insert Foleys catheter to monitor urine output.

If clinically placental abruption:

-Perform  digital vaginal examination

-If cervix not fully dilated

-If foetus is alive and gestation age is over 32 weeks, perform caesarean section

–correct clotting defect prior to operation.

-If foetus is dead or of non-viable gestational age, perform Artificial Rupture of Membranes, start oxytocin and aim to deliver within 6-8 hrs.

-If cervix almost fully dilated deliver vaginally. 

If placenta praevia confirmed by previous scan

-Perform caesarean section.

If not a confirmed placenta praevia or not placental abruption

-Perform C-section

NB:THESE WOMEN ARE AT RISK OF POST PARTUM HAEMORRHAGE.

-At delivery:

• Give intravenous 0.5 mg ergometrine or 5 units of oxytocin if hypertensive
• add 20 units of oxytocin in 1 litre Ringers lactate or normal saline and run at 30 drops per minute until patient stable and ensure uterus remains well contracted.

If bleeding mild to moderate and not life threatening

-Admit to early labour ward for bed rest

-Watch pulse and blood pressure

-4 hourly Fetal Heart Rate, pad and contraction checks

-Blood for haemoglobin, blood grouping

-Sedation may be given if patient anxious, 10 mg diazepam orally or im.

-Perform ultrasound scan:

If not placenta praevia

-Keep in hospital for observation.

-If bleeding stops, discharge 24 hrs. after bleeding has stopped

- Advise not to have sexual intercourse for two weeks

-Advise to return immediately if recurrence 

-Await spontaneous labour.

If bleeding continues but not severe:

-Keep in hospital/waiting shelter until 37 weeks 

-Watch haemoglobin

-Give haematinics

-Watch fetal growth

-Kick chart

-Induce labour at 37 weeks

If placenta praevia – Gestational  age 37 weeks or more

>Major  placenta  praevia (covers internal os) or grade 2b-perform caesarean section

>Minor; grade 1, 2a and bleeding is minimal-induce labour if cervix favourable or await spontaneous labour if cervix not favourable

Gestational age less than 37 weeks

-Keep in the hospital until bleeding has stopped, and then can be managed as an outpatient

-Repeat scan at 32- 34 weeks and again later before planning definitive mode of delivery. 

-While in hospital:>daily pad checks ,daily fetal movement chart and fetal heart monitoring.

-weekly haemoglobin and keep 2 units of blood cross matched and available

Breech presentation is associated with higher incidences of congenital anomalies (6%), preterm birth, fetal trauma (fractures, brachial plexus, visceral injury e.g.liver, brain-hypoxic, maternal trauma, low APGAR scores compared to vertex presentation regardless of mode of delivery.

There is a higher risk of cord prolapse (15% with footling breech, 5% flexed breech compared to <1% with a frank breech or vertex presentation).

Classification

1.Frank/ Extended-flexed hips and extended knees

2.Complete/Flexed-flexion at both hips and knees

3.Incomplete/Footling-extension of one or both hip

Management

Mode of delivery depends on the experience of the birth attendant and the patient’s wishes.

The  options are:

-Planned / Elective Caeserean-section, or

-External Cephalic Version(ECV) of the breech to achieve cephalic birth 

-Planned trial of assisted breech vaginal birth.

 -Elective/planned Caeserean-section is the safest way to deliver a term singleton breech presentation 

Mode of Delivery of a singleton term breech

As many breech presentations will become cephalic as pregnancy advances there is no need for action until 36 weeks.At 36 weeks consider the following:

-Ultrasound scan is performed to localize the placenta and exclude severe congenital malformation and estimate fetal weight.

-If there are no contraindications, perform Extrenal Cephalic Version(ECV).

-Absolute contraindications to ECV include>Previous caesarean section scar, Antepartum Hemorrhage, Placenta praevia,  Severe proteinuric hypertension, Premature Preterm Rupture Of Membrane with oligohydramnios, and  Severe congenital malformation.

-If ECV fails or it is contraindicated  then decide on the mode of delivery

Perform caesarean section if

>Previous caesarean section

>Previous bad obstetric outcome, death of term baby

>Associated obstetric problem, Suspected feto - pelvic disproportion; (note that if previously she has delivered a normal size baby, pelvis  is probably adequate)

>Estimated fetal weight more than 3.5kg and Footling breech presentation.

Management in labour:

If vaginal birth is the preferred route, labor augmentation and 2nd stage >60 minutes are associated with poorer outcomes.

If a decision has not been made on the mode of delivery, inform Registrar or consultant so that the decision can be made while the woman is in admission room.

First Stage

-Set up an iv line to keep vein open.

-Keep prepared for possible caesarean section.

-During every vaginal examination feel for possible cord prolapse or presentation.

-Do not do Artificial Rupture of Membranes until in advanced labour.

-Perform vaginal examination immediately after membranes have ruptured to exclude cord prolapse and to assess cervical dilation and level of presenting part.

-Assess fetal heart rate carefully during labour.

-Avoid premature pushing; No pushing should occur until the buttocks are distending the perineum. Adequate analgesia should be given. If she starts to push before cervix is fully dilated give intravenous pethidine 75mg and have naloxone ready for baby.

-Assess progress of labour every two hours in active phase- THIS INCLUDES RATE OF CERVICAL DILATATION AS WELL AS DESCENT OF THE BREECH.

-Oxytocin may be used if contractions are weak but consultant should make this decision.

ALWAYS BE PREPARED TO DO CAESAREAN SECTION IF PROGRESS IS NOT SATISFACTORY – DO NOT ALLOW PROGRESS OF LABOUR TO GO TO THE RIGHT OF THE ACTION LINE.

Second Stage

Assisted Breech Delivery

-Most of the baby is delivered by maternal effort and the attendant delivers the head.

-Put patient in lithotomy position with poles, swab and drape vulva with sterile towels.

-Empty bladder.

-Initially use “hands off” policy i.e. do NOT pull down breech that is still high.

-Also avoid spontaneous vaginal delivery because if delivery of the head is uncontrolled there is risk of injury to the brain.

-Infiltrate the perineum in case episiotomy is required. Elective episiotomy is not required especially in multiparous women. 

Even in the second stage be prepared to do caesarean section if there is no descent of the breech.

-The woman is allowed to push with each contraction and the buttocks are delivered spontaneously.

-If the legs are flexed they will fall out but if they are extended apply pressure in the popliteal fossa and grasp the ankle and sweep the foot down and out. Similarly deliver the other leg.

-Ensure the fetal back is uppermost. If it turns downwards the chin will catch under the symphysis pubis and cause difficulty in delivery of the head

-If the arms are across the chest they will deliver spontaneously. As the anterior shoulder blade appears, place two fingers of the appropriate hand (right hand for right shoulder) over the clavicle around the shoulder and down the humerous to the forearm to bring it down.

-Grab ankles and swing upwards to deliver the other arm similarly.

Allow the body to hang until hairline is visible and then deliver the head using any of these methods:

• Forceps
• Laying the child along one arm, place the middle finger of that hand in the mouth, the index and ring fingers along the cheek bones. Traction by these fingers promotes flexion of the head. Place the index finger and thumb of the other hand over one shoulder, use the middle finger to press over the occiput and the other two fingers over the other shoulder. Traction will deliver the head by flexion. (MauriceauSmellie-Veit manoeuvre).
• Grasp the feet and while under slight traction swing the baby in an arc over the maternal abdomen. This will bring the head down and free the mouth. Deliver the rest of the head by further swinging over the abdomen but ensuring it does not pop out. An assistant is usually required to hold the baby while you control the delivery of the head (Burns-Marshall method).
• Extended arms-the anterior shoulder is above the symphysis pubis and the posterior shoulder is below the sacral promontory. Therefore grasp the fetus at the pelvis and pull gently while rotating the posterior shoulder to the front. That means rotate anticlockwise if the back is to the mother’s left and clockwise if the back is to the mother’s right. Deliver the arm and then reverse the rotation 180 degrees, using the delivered arm for traction and bring the posterior shoulder to the front (Lovset’s manoeuvre).
•  

Breech Extraction

The breech is grasped by the foot and pulled down to deliver the body up to shoulders as opposed to spontaneous delivery of the breech up to the shoulders.

Indications

-Delivery of 2^nd twin which maybe breech or transverse with intact membranes

-Intrauterine Fetal Demise with cervix fully dilated

 Preterm Breech

There is insufficient evidence regarding outcomes by mode of delivery. Outcomes in premature breech infants are mainly related to prematurity ± fetal anomaly.

 Breech  2^nd Twin

Vaginal delivery of the 2^nd non-vertex twin is a reasonable management option.

Total breech extraction is associated with shorter maternal stay and lower neonatal pulmonary disease, infection and hospital stay compared to cephalic version.

Malpresentations of the vertex

-Face presentation

Mento-anterior position:expectant approach/allow labor to progress. Use augmentation sparingly.

Mento-posterior/transverse:if no rotation to mento-anterior position do Caesarean section

Note. Many anencephalic fetuses have a face presentation.

Brow presentation

For term fetus, the mento-vertical diameter (13.5cm) will not pass through the birth canal: vaginal birth not possible unless fetus is pre-term, or flexes to vertex, or extends to face presentation. If brow presentation persistent, do Caesarean-section.

Shoulder presentation as in a transverse lie

-There is increased risk: of cord prolpse, for uterine rupture & difficulty of vaginal delivery.

-Diagnosis: Abdominal or vaginal exam and USS confirmation if available. ? Before term- await spontaneous version to cephalic

-At term perform ECV if no contraindications or do elective Caeserean-section at 39 weeks

Compound presentation 

Occurs 1 in 1000 deliveries but higher with prematurity, multiple gestations, polyhydramnios & CPD.

Diagnosis

-A fetal extremity is presenting alongside the vertex or breech during vaginal exam

-A common complication is cord prolapse, so if possible do continuous electronic fetalheart rate monitoring.

-Determine whether the prolapsed fetal part is a hand or foot.

Treatment

>Vertex +hand/upper extremity- gently reduce –aim for vaginal birth

>Vertex+ lower extremity-perform caesarian section

>Breech + lower extremity is a footling breech: do caesarian section

Risk factors

-Obstructed labor e.g. cephalopelvic disproportion/abnormal lie

-Previous uterine surgery: prior Caesarean-section, myomectomy, previous uterine perforation from evacuation of the uterus/dilatation and curratage.

-Grand multi-parity, especially, with use of oxytocin/prostaglandins/misoprostol.

-Trauma

-Uterine over-distension

Rheumatic heart disease is the most common heart disease.

Other  types include congenital heart disease, hypertensive, thyroid disease and cardiomyopathy.

Dangers:cardiac failure, endocarditis, and cardiac arrhythmias.

Patients with pulmonary hypertension from whatever cause have a case specific maternal mortality rate of 30-50%. Termination of pregnancy for maternal interests should be offered to the woman .Anticoagulants  are to be given to women at high risk of thromboembolism e.g. prosthetic heart valves

Risk factors for cardiac failure include:

>Anaemia

>Fever or infection

>Arrhythmias

>Hypertension

>Physiological changes in pregnancy associated with increased blood volume.

Echocardigraphy abnormalities

-Aortic valve area <1.5 square cm

-Mitral valve area <2 square cm

-Ejection fraction <40%

-Peak left ventricular outflow gradient > 30mmHg

Antenatal Management:

-Extra rest is essential AND do not allow to gain too much weight

-Prevent anaemia- prophylactic iron and folate

-Admit to hospital 2-4 weeks before planned delivery

-Most go into labour spontaneously

Labour Management

Ensure emergency trolley is by the bedside. Trolley must contain oxygen, morphine, aminophylline, digoxin, frusemide and ETT with Ambu bag.

First stage:

-Nurse in semi sitting position

Give adequate analgesia ( Morphine 5mg  every 4 hours i.m or 10 mg every 4 hours orally) or pethidine hydrochloride  50-100mg i.m every 3-4 hours. 

-Watch pulse, respiratory rate and blood pressure every 15 minutes

-Keep accurate fluid balance to ensure no fluid overload with risk of cardiac failure

-Antibiotic prophylaxis- Ampicillin 500mg iv stat and 6 hourly for 6 doses and Gentamycin 80mg im stat and 8 hourly for three further doses.

-If augmentation is required this decision should be made by a senior member. Use high concentration of oxytocin (150 ml bag.) 

-Oxytocin may be used with or without Frusemide

-Nurse in semi-recumbent position 

-Avoid aorto-caval compression

-Shorten the second stage of labour- forceps or vacuum

-Avoid raising legs into lithotomy position

-Avoid ergometrine in the third stage of labour

-Avoid beta-sympathomimetic drugs which cause tachycardia and vasodilatation

Second stage:

-Deliver in semi sitting position with legs hanging over the edge of the bed.

-When there is urge to push let patient give short pushes with mouth open

-If severe  cardiac failure assist with vacuum.

-Do not use ergometrine with anterior shoulder because of risk of cardiac failure, give 5u oxytocin (im) to prevent PPH

-If patient has been unstable previously give 20-40mg frusemide iv immediately after delivery.

Puerperium:

-Sedate and allow to rest

-Close observation of pulse, respiratory rate and blood pressure in Early Labour Ward.

-Give family planning advice before discharge

-Breast feeding is not discouraged 

-Pulmonary oedema is a medical emergency that should be anticipated- nurse in semi sitting position, clear airways and give oxygen, intravenous aminophylline, morphine, frusemide and digoxin

-Peripartum cardiomyopathy should be suspected in a woman with acute dyspnoea and tachypnoea and tachycardia

-Use of ACE inhibitors is safe during breastfeeding

Fetal risks

>Fetal death

>Intrauterine growth restriction

>Fetal congenital malformations

Risk factors for diabetes:

>Family history of diabetes

>Previous large babies

>History of diabetes in previous pregnancy

>Previous unexplained stillbirth or neonatal death

>Previous congenitally abnormal baby

>Obesity BMI>30

>Glycosuria on two occasions

>Recurrent candidiasis or Urinary Tract Iinfections

Diagnosis:

• Screening test on all above women – glucose load test-  non fasting patient, give 50g glucose and measure blood sugar 1 hour later- glucose level >_7.8mmol/l is abnormal and she should then have a full Glucose Tolarence Test. If this is normal repeat at 28, 32 and 36 weeks.
• Glucose tolerance test- 75g glucose after overnight fast. Abnormal if fasting level >7mmol/l. If 2 hour level >10mmol/1 (between 7-10 mmol/1 is defined by WHO as impaired glucose tolerance).

 Risks:

Maternal: keto-acidosis, infections (candidiasis and urinary tract infection) retinopathy, nephropathy, pre-eclampsia, and polyhydramnios.

Fetal:congenital malformations, preterm, macrosomia, IUGR, intraurine fetal death, and birth trauma.

Neonatal:hypothermia, hypoglycaemia, hypocalcaemia, infections, hyperbilirubinaemia and polycythaemia.

Management:

Pre conceptual care:

-Use of contraception is advised until good glyceamic control is achieved as assessed by HbA1c levels< 6.1%

-Assess for diabetic retinopathy and nephropathy before pregnancy

-Folic acid supplementation 5mg/day until 12 weeks of gestation to reduce the risk of fetal neural tube defects 

-Women at risk of diabetes e.g. obese,  should be counseled about weight loss, diet and exercise prior to conception

-Women with diabetes should be advised on the importance of glycaemic control before and during pregnancy to reduce the risk of miscarriage, congenital malformations, still birth and neonatal death.

-Angiotensin converting enzyme inhibitors, Angiotensin II receptor antagonists and statins should be discontinued before conception or as soon as pregnancy is confirmed.

Care during pregnancy:

1. Diabetic control:diet and insulin (short & medium acting) or oral hypoglycaemics. Good control of blood sugar crucial-may need to admit frequently into hospital. Avoid hypoglycaemia. Aim at keeping sugars 3.5-6.0 mmoles/l as this is associated with optimal outcome for mother and baby.

2. Assess fetal growth: macrosomia as well as IUGR; scan at booking and at 28, 32, 36 weeks and assess fetal well-being from 32 weeks by daily kick chart and once or twice weekly CTG.

Obstetric care:  see frequently – every two weeks until 36weeks, then weekly until delivery .Carefully observe blood pressure.

3. -Pick up complications early- usually the better the control the fewer the complications. Assess for diabetic retinopathy and nephropathy.
4. -Fetal anomaly scan should be offered at 18-20 weeks gestation
5. -Assessment of fetal well being should be done regularly ( every 4 weeks from 28 weeks) Diabetic retinopathy , nephropathy and neuropathy should be evaluated for during pregnancy.
6. -Women with albuminuria of >5g/day should be given thromboprophylaxis.
7. -Use of glycosylated hemoglobin levels is limited in the second and third trimester
8. -Glucose profile should be done every 1-2 weeks
9. -Steroids for fetal lung maturity should be given cautiously in diabetics. If antenatal corticosteroids are given, insulin requirement may increase and so close glucose level monitoring should be done for up to 5 days after use of steroids

Delivery

If diabetes is well controlled, induce labour after 38 weeks and deliver vaginally if there are no obstetric contraindications.

Labour

If inducing labour: starve from midnight, measure fasting blood sugar at 0600hrs give half her morning dose as soluble insulin and start 5% dextrose infusion and hourly  insulin on a sliding scale checking blood glucose hourly (using dextrostix) and maintaining level between 4-7 mmoles/l. 

-give oxytocin via separate saline litre

-during labour monitor fetal heart rate

-adequate analgesia

-at delivery be aware that shoulder dystocia may occur.

Intrapartum

-Intrapartum strict glycaemic control should be maintained.

-Hourly glucose checks are to be done and levels to be kept between 4-7mmol/L

-An infusion of insulin 50IU in 50mls saline, and 10mmol of KCL in 500ml of 5% dextrose  can be given to maintain glycaemic control may be given as a continuous infusion.

If elective caesarean section:

Starve from midnight

Measure fasting blood sugar and urea and electrolytes at 0600hrs

• put up 5% dextrose with 10 units soluble insulin and 1g potassium/litre and run at 100 mls per hr(Do not give the usual dose of insulin)
• .Monitor blood glucose hourly
• Consult the anaesthetist.
• Baby is at risk of the above complications and to prevent hypoglycaemia the baby is put to the breast immediately after delivery. Paediatrician must see the baby.
• After delivery insulin requirements revert to pre-pregnancy levels within 24 hrs of delivery
• Observe in Early Labour Ward for 6 hrs and use sliding scale to assess insulin requirements.
• Encourage breast feeding.
• Give advice on family planning. Oral contraceptives can be used but watch diabetic control. If they want more children , advise on pre-pregnancy counselling before next pregnancy.

Hypertensive diseases of pregnancy are one of the major causes of maternal morbidity and mortality.

Classification of hypertensive diseases in pregnancy:

1.Pregnancy induced hypertension (PIH) also called gestational hypertension.

2.Preeclampsia.

3. Chronic hypertension

4.Chronic hypertension with superimposed preeclampsia.

5. Eclampsia

Definition

PIH is defined as a blood pressure of 140/90 mmHg or higher on two occasions, at least six  hours apart,  observed after 20 weeks of pregnancy and which resolves within 12 weeks post delivery. 

Severe PIH is a diastolic blood pressure ≥ 110 mmHg or systolic blood pressure ≥ 160 mmHg confirmed by a repeat measurement after resting the patient for 10-20 minutes.

Preeclampsia

Is PIH with proteinuria (>0.3g in 24 hours). Urinalysis of  ≥2+

Imminent eclampsia/Severe Preeclampsia:

Severe PIH with proteinuria in addition to symptoms such as headache, drowsiness, visual disturbance, epigastric pain, nausea or vomiting. There may be tenderness over liver with increased reflexes or clonus.

Eclampsia

Is defined as the occurrence of one or more convulsions superimposed on preeclampsia. Development of eclampsia is not related to level of blood pressure alone. All women who have a convulsion during pregnancy should be managed as eclamptics until proven otherwise.

Risk Factors:

-Previous history of PIH, history of chronic hypertension or PIH in mother or sisters.

-Primigravida  

-Women over the age of 35yrs.

-BMI >30  

-Black race

-Antiphospholipid syndrome

-Multiple pregnancy

-Diabetes mellitus

MANAGEMENT OF PIH and Preeclampsia

The disease is divided into mild, moderate and severe.

Mild PIH- systolic: blood pressure 140-149 mm Hg and/or diastolic pressure 90-99 mm Hg with no protenuria.

Moderate PIH: Systolic blood pressure 150-160 mm Hg and/or diastolic pressure 100-109 with no proteinuria.

Severe PIH: systolic blood pressure 160 mm Hg or above and/or diastolic blood pressure 110 mm Hg or more.

Mild, moderate and severe preeclampsia is the above blood pressure readings with a +, ++, and +++ of proteinuria respectively.

Management during the antenatal period 

Mild hypertension : Diastolic BP 90-99mmHg, no proteinuria

-Manage as outpatient

-Weekly antenatal  visits 

-Monitor for development of proteinuria

Moderate hypertension :Diastolic BP 100-109mmHg, no proteinuria

-Admit

-Monitor BP 4hourly

-Monitor for development of proteinuria

-Start on antihypertensives

-Consider methyldopa initially

-It may be necessary to add nifedipine or  prazosin if BP readings remain high

-Assess foetal well-being

-Plan for delivery after 37 weeks

Severe hypertension : Diastolic BP ≥110, No proteinuria

-Monitor BP 4hourly

-Monitor for development of proteinuria

-Assess foetal well-being

-Start on antihypertensives  as for moderate hypertension

-Add  Nifedipine 10mg po stat for DBP ≥110 

-Aim to deliver at term but earlier delivery may be  indicated  if there are foetal or maternal complications

Pre-eclampsia

Severity of Preeclampsia

The differentiation between mild and severe preeclampsia can be misleading because mild disease may progress rapidly to severe disease.

Management of severe preeclampsia

-Manage as inpatient

• FBC, U&E, LFT
• 4hrly BP monitoring
• Assess foetal well-being
• Daily urinalysis
• Watch for signs and symptoms of imminent eclampsia
• Start on antihypertensives
• Pre-eclampsia can progress rapidly, so women should be monitored closely 
• Plan delivery at term in mild pre-eclampsia 
• Consider  immediate delivery in severe disease 
• Give steroids if gestation is <34 weeks and  delivery is not imminent

Management in Labour

• Monitor blood pressure 1-2 hourly and urine output and proteinuria 4 hourly
• Monitor reflexes 2 hourly
• Adequate analgesia for pain
• If imminent eclampsia/severe preeclampsia use prophylactic magnesium sulphate
• Careful monitoring of fetal heart
• Maintain systolic blood pressure below 160 and diastolic below 100 with hydrallazine  or nifedipine
• Give oxytocin and not ergometrine in 3^rd stage of labour 
• Keep in Labour ward or early labour ward after delivery to observe 1-2 hourly blood pressure for 4-6 hours before discharging to post natal ward.

 ECLAMPSIA AND IMMINENT ECLAMPSIA

When a woman is admitted with a convulsion think also of other causes of convulsions:

• Epilepsy
• Cerebrovascular accident
• Meningitis/cerebral infection
• Cerebral malaria
• Hypoglycaemia, uraemia, or hyperventilation

Management:

• Call for help from a senior colleague
• Manage airway and breathing and secure an intravenous line. Place patient in  recovery semiprone position with neck extended
• Stop convulsions and prevent further convulsions- Give magnesium sulphate. 
• Control blood pressure
• Plan for delivery
• Restrict fluids 

 Magnesium sulphate regime

• Magnesium sulphate 4 grams slowly intravenously over 5 minutes FOLLOWED IMMEDIATELY by 5 grams into each buttock by deep intramuscular injection. i.e. a total of 14 grams.  
• Repeat 5 grams intramuscularly every 4 hrs only if:  
• - Respiratory rate is over 16 per minute
• -Urine output in the previous 4 hrs was above 100mls 
• -Knee jerk is present.
• If any of above is absent, omit the next dose and wait for 4 hours and re-test again before giving the injection.
• Continue Magnesium sulphate for 24 hours after delivery or last fit whichever comes last. Magnesium sulphate is the drug of choice for the management and prevention of further fits. 

 Diazepam regime

• When magnesium sulphate is not available 40 mg diazepam in 1 litre normal saline/ringers lactate and run at about 30 drops per minute or at a rate to keep patient sedated but rousable.  
• Continue for 24 hrs after delivery or after last fit and then tail off over the next 24 hours

NOTE: A combination of diazepam and magnesium sulphate can be fatal as they are both CNS suppressants.

Note: if there are repeated seizures alternative agents such as diazepam or phenytoin may be used but only as single doses. If convulsions persist consider intubation to protect the airway and maintain oxygenation and transfer to a facility with ICU.  

• Control blood pressure with hydralazine or nifedipine 

 Other points of management

• Catheterize to monitor urine output 2 hourly
• Restrict fluids to 40 to 80mls per hour i.e (1 to 2L in 24 hours) to prevent cerebral and pulmonary oedema. 
• FBC, bed side clotting time, urea and electrolytes 
• Group and retain
• If competent,  put in CVP line to guide fluid input and maintain CVP 10-12 cms water.
• If urine output less than 25 mls/ hr discuss with senior. Do not give frusemide.
• Plan delivery- once blood pressure is stabilized and fits are controlled, assess fetal state .
• If in labour and no fetal distress- allow to labour as long as delivery is likely to occur within 6-8 hours. 
• If IUFD, induce and aim to deliver within 6-8 hours provided she remains stable.
• If not in labour but cervix is favourable and no fetal distress and delivery likely within 6-8 hours – Artificial Rupture of Membranes and oxytocin.

Perform caesarean section if:

• Cervix unfavourable
• Unconscious
• Fetal distress
• Blood pressure is uncontrolled
• Progress slow

Post-delivery:

• Keep in high care for 24-48 hours
• Restrict Intravenous fluids.
• Maintain anticonvulsants for 24 hours after delivery or last fit
• Control blood pressure
• Monitor urine output, respirations, blood pressure, level of consciousness.

It is essential that a cause be determined whenever possible for advice in future pregnancy.

Possible causes include:

Maternal causes – diabetes, hypertension, infections like syphilis, malaria and CMV and placental abruption.

Fetal causes- malformations, cord complications and severe IUGR.

Diagnosis must be confirmed by ultrasound scan except when associated with severe APH.

Management:

-Counselling and emotional support is crucial to help with grief and for future pregnancies.

-Discuss value of post-mortem.

-Investigations include VDRL/TPHA,FBC, glucose load test, antinuclear factor, Rh group.

-If IUD has been long standing (3-4 weeks) check platelet count and if this is low do a coagulation screen.

Plan delivery:

<13 weeks

Option A

-Medical treatment  with misoprostol

-Might need to admit if necessary

-800µg vaginal /600µg Oral

-Monitor for bleeding

-If no explulsion  of RPOC  or bleeding can repeat  dose  in 12hrs

-Analgesia should be given once contractions start

IF EXPULSION IS NOT COMPLETE TO BE COMPLETED WITH EVAC/MVA

Option B

D&C/EVAC

≥13 weeks

Induce labour- this is USUALLY done as soon as diagnosis is confirmed. There are several ways of inducing labour.

Misoprostol use

Dose depends on gestational age

13-17wks

Vaginal 200µ 6-12hrly for 4doses. If first dose does not lead to effective contractions then next dose 400µg. Maximum daily dose 1600µg.

18-26wks

Vaginal 100µg 6-12hrly for 4doses. If first dose fails then next dose should be 200µg. Maximum daily dose is 800µg.

Beyond 26wks

If cervix not ripe(Bbishop score ≤6) cytotec 25-50µg repeat every 6hrs for 46doses. If cervix is ripe (bishop score≥6) then oxytocin can be used.

At this gestation, before repeat misoprostol is given, assessment of uterine contractions SHOULD  be done and if 2 or more contractions are palpated in 10min then the dose should not be repeated.  If there is need to augment labour this should not be done within 6hr.

Use of misoprostol in the presence of uterine scar is discouraged and should be done on the advice of a consultant. The lowest doses are preferred.

Use misoprostol with caution in  women who are more than para 3.Induction with extra amniotic saline infusion or by use of the traction catheter are the preferred modes of induction.

Extra amniotic saline infusion

-Insert intracervical catheter as for traction catheter. 

-Inflate balloon with 20 mls water and apply slight traction and strap catheter to midthigh. 

-Attach 1 lLitre saline bag to the catheter via a fluid giving set and run saline at 30 drops per minute up to 2 lLitres.

-Explain to the patient that she will feel wet as the saline will escape through the cervix and that she must stay in bed while the drip is running.

-Send her to LW as soon as contractions are established.

Prostaglandins

Pessaries/ vaginal tablets as for induction.

Prostaglandin PGF 2α extra amniotic gel is not reaily available

Traction catheter followed by oxytocin as soon as catheter  falls out

Management in labour:

-Delay ARM until in established labour, give oxytocin if progress slow

-Give adequate analgesia and commence on amoxicillin 500mg T.D.S and metronidazole  400MG t.d.s per oral

-Show the baby to the mother if she wishes to see after cleaning and draping. It is good practice to encourage mothers to see the baby.

-Examine foetus for congenital malformation with post mortem if possible

-Suppress lactation- firm breast support (not just a bra), do not express. Bromocriptine (2.5 mg twice daily for 10-14 days) may be used if no response to above.

-Organise post natal follow-up to discuss results and give advice on future pregnancies.

The clinical requirement for induction of labour arises from circumstances in which it is believed that the outcome of the pregnancy will be better if it is artificially interrupted rather than being left to follow its natural course. Below are some of the indications for induction of labour.

-Prolonged pregnancy

-Preterm prelabour rupture of membranes

-Term prelabour rupture of membranes

-Preeclampsia

-IUGR

-Diabetes mellitus

-Intrauterine fetal death

-Maternal request for induction 

Prior to every induction

-Confirm the indication 

-Explain the benefits and risks of induction and  ? Get written or verbal consent.

-In case of failed induction ensure caesarean section is an acceptable mode of delivery.  ? Examine the abdomen for:Height of fundus, presentation, lie, descent, fetal Heart. If available perform a non-stress test.

-Assess the cervix to get bishop score. 

Risks of induction

-Iatrogenic prematurity

-Hypertonic uterine contractions leading to fetal distress or uterine rupture

-Failed induction

-Neonatal jaundice 

Methods of induction

Bishop score is greater than or equal to six. 

-Amniotomy 

-Amniotomy plus oxytocin

-Oxytocin

-Sweeping membranes

Bishop score less than six

-Prostaglandins

-Foley’s catheter

-laminaria sticks

Oxytocin and amniotomy

-At 0800 hrs assess cervical score and if the score is 6 or more perform ARM and commence oxytocin infusion. 

-Start with low dose initially and gradually increase to produce effective contractions. The aim is to have at least 3 contractions in ten minutes.

-Generally for primigravida start with 4 units in 1 L Ringers Lactate at 10, 20, 40 drops per min. With multiparous women start with 1 unit and increase to 4. Increase dose every 30 mins and aim to get strong contractions within 4 hrs of commencement.

-Decrease the infusion rate as soon as contractions are strong.

-Side effects of oxytocin include hyperstimulation and water intoxication. 

Traction catheter

-Insert size 18 or above Foleys catheter through cervix, fill balloon with 40 to 80mls of water for injection and then pull and strap the end of the catheter down to mid leg and not thigh. Ask the woman to keep her leg straight until the catheter falls out. When properly done, the catheter usually comes off within a few hours.

-Oxytocin can then be put up immediately after the catheter falls out with or without ARM 

Extra-amniotic Prostaglandin gel

-Pass a size 18 Foley catheter through the cervix as above. Inflate balloon with 30 mls water and knot the distal end. Inject gel into catheter (20mls) and flush all gel in tube with 10mls of air. 

Prostaglandin E2 vaginal tablets

-One 3 mg or three 0.5 mg tablets can be inserted into the posterior fornix every 8 hours. 

Extraamniotic saline infusion

-As described for IUD, can also be used for induction of labour for live foetuses. 

Misoprostol

This is a prostaglandin E1 derivative. It is effective as an induction agent given both orally or vaginally. Currently available preparations are 100 microgram and 200 microgram oral tablets which must be cut or made into suspension to achieve lower doses, but uniform concentration and accurate drug delivery is not guaranteed

-Both the vaginal and oral doses are effective and a single dose should not exceed 50ug

 Oral

-50mcg or quarter tablet swallowed with some water. This can be repeated after 4hrs up to a maximum of four doses

Or 

-A 200mcg tablet dissolved in 200mls of water and stirred into a uniform suspension. 20mls of this suspension is then taken every 2 hours up to a maximum dose of 200mcg   

Vaginal

-50mcg or quarter tablet inserted into the posterior fornix vaginally. This can be repeated after every six hours up to a maximum of four doses. 

NOTE: Always assess the cervix and uterine contractions before the next dose. If the cervix is 3cm or more and there are no contractions ARM can be done and oxytocin put up.

Contraindications to Misoprostol

-Previous scar

Use with caution in:

-Suspected macrosomia ? Para 3 and above.

-Multiple pregnancy o In this case, use 25 ml of the solution (200mcg in 200ml) every 4 hours

-If labour has not occurred within 24 hours , review all parameters, including cervical ripening  before repeating cytotec

-Consider ARM +/- use of oxytocin at least6 hours after the last dose of Misoprostol

Always think of twins if there is a family history or previous history, uterus feels larger than gestational age by dates, palpation is difficult or there is polyhydramnios. Often three or more poles or multiple fetal parts are palpable.

Antenatal Complications:

-Anaemia

-Urinary tract infection

-Congenital abnormality

-Pregnancy induced hypertension

-Antepartum haemorrhage (placental abruption and placenta praevia)

-Preterm labour and prelabour rupture of membranes, ? Polyhydramnios and malpresentations

Management:

-Watch haemoglobin- advise on good diet and start on iron and folate supplementation  ? Encourage extra rest periods and less heavy work.

-Watch urine for protein

-Watch blood pressure every two weeks up to 28 weeks and then weekly

-Ultrasound scan in the first trimester  to confirm gestational age and chorionicity

-Watch growth of babies carefully preferably by scan at 28, 32-34, 36-38 weeks; this is especially so for monozygotic twins.

-Watch for fetal wellbeing from 36 weeks, preferably weekly ? Plan mode of delivery

LABOUR

Complications:

-Malpresentations

-Preterm labour

-Cord prolapse

-Post-partum haemorrhage

Management:

>Assess stage of labour

>Perform    vaginal   examination         to            assess     presentation          and         exclude    cord prolapse/presentation

>Labour is managed according to the presentation of the first twin o If transverse, caesarean section

• If breech, often small and vaginal delivery almost always possible
• If cephalic, vaginal delivery

Delivery of the first twin is usually uncomplicated but conduct delivery in lithotomy position and Registrar should be nearby.

>After delivery of the first twin, ensure cord is well clamped because if twins are uniovular the unborn baby might bleed if the cord were not firmly clamped

>Perform abdominal examination to confirm presentation of second twin

>Listen to the fetal heart

>Aim to deliver the second twin within 30 minutes o If transverse  or breech attempt to perform ECV if membranes are intact o If ECV fails, perform internal podalic version i.e grab foot and gently pull down and rupture membranes and perform breech extraction

>If cephalic, perform ARM, add oxytocin to stimulate contractions and:

-Conduct delivery in the usual way o Maximum interval between deliveries should not be more than 30 minutes.

Transverse lie of the second twin

If the uterus has clamped down onto the baby after rupture of membranes one may need to perform caesarean section. If membranes are intact perform internal podalic version and breech extraction.

Delay in birth of second twin

If uterine contractions are poor or do not resume within 20 minutes of delivery of the first twin, start-up oxytocin infusion.  This should have been avoided by having oxytocin infusion ready just before delivery of the first twin.

Fetal distress

Expedite delivery by vacuum extraction or caesarean section

Cord prolapse:

Expedite delivery

Maternal haemorrhage before birth of second twin

-If binovular, placenta of the first twin separates and may deliver before delivery of the second twin. This is a warning that placenta of the second twin may also be starting to separate and will cause hypoxia of the second twin. Rupture membranes and deliver second twin as soon as possible.

Undiagnosed twins

-Ergometrine or syntometrine  might have been given already and the resulting contraction may cause anoxia. Uterine rupture may also occur. Immediate delivery is needed- caesarean section may be required.

-Prevent post-partum haemorrhage: give iv ergometrine or oxytocin if hypertensive and put 20 units oxytocin/litre as slow iv infusion.

Demise of one twin is an indication for immediate referral to a tertiary institution

Definition: pregnancy lasting 42 completed weeks or more

Diagnosis:

A carefully obtained history is the cornerstone of appropriate management. Detailed information on menstrual pattern and the accuracy of the dates of the last normal period are important. Use of hormonal contraception, abortion, or lactation immediately preceding the pregnancy should be obtained accurately at the first booking visit. This will be the basis of deciding on whether dates are certain or not.

If the midwife saw her before 24 weeks, correlation between gestation by dates and by palpation would be useful.  If she had an early scan this will help confirm dates.

Management:

-Re-evaluate menstrual history

-Assess cervix (Bishop’s score) for possibility of successful induction o If cervix is favourable labour can be induced (see induction of labour) o If cervix unfavourable, admit to ripen the cervix and induce only when cervix unfavourable.

-NST twice weekly if waiting for more than a few days.

-Aim to deliver between 41 and 42 weeks.

Onset of Labour before 37completed weeks of gestation.

If duration of pregnancy is unknown, the diagnosis is made on account of EFW of <2500g. Risks of complications are low if EGA >34weeks.

In a patient with preterm labour ,regular & usually painful uterine contractions are observed at least 2 in 10 minutes with or without  history  of rupture of membranes +/- cervical effacement and/or dilatation without a history of rupture of membranes

AETIOLOGY

Maternal factors

1. Infections:

>Clinical Chorioamnionitis

-Pyrexia

-Maternal or fetal tachycardia,

-Uterine tenderness and 

-Foul smelling liquor

>Subclinical chorioamnionitis

-No signs of chorioamnionitis are present

-Diagnosis made by culture or histologically

>Maternal Pyrexial illness e.g. Malaria,Acute Pelonephritis

Uterine Factors:

>Congenital Uterine abnormalities e.g. bicornuate uterus,uterine fibroids

>Cervical incompetence.

Fetal factors:

-Multiple pregnancy                 

-Polyhydramnios

-Congenital fetal abnormalities e.g neural tube defects, gastrointestinal defects, tracheoesophageal fistula

Placental factors:

-Placenta abruption

-Placenta praevia

High risk patients for Preterm Labour 

-Previous preterm labour

-Unbooked patients

-History of early pregnancy bleed or draining liquor

-Poor socioeconomic status

-Under nutrition

-Smoking, alcohol and habit forming drugs.

Management of Preterm Labour               

-Determine the duration of pregnancy as accurate as possible

-Listen to fetal heart.

-Duration of 34-36 weeks : Allow labour to continue

-Duration of 28-33 weeks :

• Referral to hospital with Neonatal Intensive care facilities.
• The best method of transporting a preterm baby is in utero.
• Tocolytics:

-Nifedipine 30mg  orally then 20mg 8 hourly OR

-Indomethacin 100mg rectally 12 hourly(up to 32weeks)  OR

-Nebulisation with Salbutamol OR

-Atosiban(Tractocile) 1-32uM

CONTRAINDICATIONS TO TOCOLYSIS

-Fetal distress

-Pregnancy duration  >34weeks or <24weeks.

-Chorioamnionitis

-Intrauterine fetal death

-Congenital fetal abnormalities incompatible with life

-Pre-eclampsia

-Antepartum hemorrhage

-Cervical dilatation>6cm

-Serious intrauterine growth restriction

-Preterm rapture of membranes.

Corticosteroids

-Best between 28 and 32 weeks of gestation) o -Betamethasone 12mg IMI 24hours apart OR o -Dexamethasone 12mg IMI 12hours apart.

Entonox is ideal method of pain relief (Avoid Pethidine as it suppresses newborn respiration).

Definitions:

• Pre-labour rupture of membranes(PROM); Rupture of membranes after 37 weeks of gestation, not followed by uterine contractions within one hour.
• Preterm pre-labour rupture of membranes(PPROM);rupture of membranes before 37 completed weeks of gestation ,in the absence of uterine contractions.

Diagnosis

Pregnant woman <37 weeks of gestation, with a history of a sudden gush of a large volume of fluid vaginally, followed by continuous leakage of a small volume of watery fluid.

Confirmation of diagnosis

-Sterile speculum examination

-Visible drainage of liquor through the cervical os

-Liquor accumulates in the posterior blade of the speculum or in the posterior fornix

-Drainage can be demonstrated by asking the patient to cough

-Reduced  risk of ascending  infection

-Possibility of cord prolapse can be demonstrated

-Demonstrates cervical effacement and dilatation

-pH testing(pH>7 alkaline) or turns red litmus paper blue 

-Fferning test

• collect fluid for m/c/s
• fetal lung maturity can be demonstrated(L:S ratio or phospholipid glycerol)

 NB: NO DIGITAL VAGINAL EXAMINATION. It has no value in determining the rupture of membranes and merely increases the risk of infection.

Management

-If the patient is in labour; Allow the labour to progress , start antibiotics (Erythromycin 250mg qid orally)

Indications for immediate induction of labour (or Caesarean section):

-Pregnancy duration >34 weeks or <28 weeks

-Fetal distress

-Cord prolapsed

-Intrauterine fetal death

-Severe congenital fetal abnormalities

-Clinical signs of chorioamnionitis

-Other obstetrics complications e.g preeclampsia,diabetes

-Confirmed fetal lung maturity

-Pregnancy duration 28weeks to 34 weeks

Conservative management.

-Admit for bed rest:NB  NO DIGITAL VAGINAL EXAMINATION

-Monitor fetal wellbeing 

-Kick chart

-Symphysio-fundal height measurement

-Four hourly fetal heart monitoring

-Weekly Non Stress Test or Ultrasound scan

-Antibiotics(Erythromycin 250mg qid orally)

-Corticosteroids(Betamethasone 12mg IMI x2 doses

24hours apart or Dexamethasone 12,5mg x2 doses

12hours apart)

-Continuous observation for possible signs of infection.

-Maternal pulse rate ,temperature and fetal heart rate 4hourly

-Twice daily abdominal palpation to detect uterine tenderness

-Pad/Contraction checks and observation for possible offensive smell of the liquor

-Full blood count

-Pregnancy is allowed to continue until complications develop e.g chorioamnionitis, fetal distress, labour starts spontaneously or gestation reaches 34 weeks.

-If draining totally ceases, the pregnancy is allowed to continue until she goes into spontaneous labour 

-Patient is discharged from hospital if there is no draining for at least 48hours

-Patient must be reviewed weekly until 34 weeks gestation. 

Prelabour Rupture of Membranes

-Rupture of membranes after 37 weeks of gestation ,which is not followed by labour within one   hour.

-If not complicated by infection ,wait for 48hours before induction of labour. Cervix becomes more favourable, which increases the chances of successful induction.

-Induction should be initiated at a more practical and convenient time of the day. 

-During this waiting period 80% of patients will go into spontaneous labour. 

-If complicated by chorioamnionitis, induce labour immediately or perform caesarean section.         

Introduction

Decision on mode of delivery must be made at the antenatal clinic by a Registrar / Consultant by 36 weeks. In making a decision, take into account obstetric outcome in previous pregnancy as well as complications in the index pregnancy. If there is obvious CPD, breech presentation and other malpresentations ,multiple pregnancy or previous upper segment caesarean section in a woman with one previous Caesarean section, vaginal delivery is contraindicated. If the decision has not been made at the antenatal clinic please consult Registrar on admission in labour.

For all women who have had a myomectomy, perform elective LSCS, unless there is information available that the myomectomy did not breach the endometrial cavity.

Management in labour:

-Put up an iv canula to keep vein open

-Send blood for Hb and group and retain serum

-Start partograph

-Monitor fetal heart, maternal pulse and blood pressure carefully 

-Perform vaginal examination every two hours and observe for fresh bleeding

-Monitor progress of labour- expect to be to the left of the action line

-Oxytocin is generally only used to initiate contractions but not to augment contractions that are strong but thought to be in coordinate.

-Decision to use oxytocin should be made by Consultant

-After delivery observe in ELW for vaginal bleeding. Exploration of uterine scar is not routinely performed after delivery unless there is excessive bleeding or one suspects uterine rupture.

Introduction

The prevalence of HIV in Zimbabwe is 13.8. National Prevention of Mother to Child Transmission (PMTCT) guidelines are modified from regularly revised WHO guidelines.

Classification

Based on current evidence 2 groups can be defined based on CD4 cell counts: 

≥ 350 cells/ml - patients not yet in need of HAART for their own health;

<350 cells/ml - patients should be initiated and continued on HAART.

RISKS

-HIV vertical transmission to the foetus and infant of about 30% if there is no intervention

-Increased Maternal, Neonatal and Infant mortality (MMR.NMR,IMR)

-Increased maternal morbidity - anaemia, sepsis, opportunistic infections, HIV-related comorbidities

-Increased foetal and neonatal morbidities- IUGR, Preterm deliveries and associated complications, Stillbirths.

ANTENATAL CARE

Ideally couples should know their HIV status before conception but all women should be offered HIV TESTING (Provider Initiated) at their booking visit or at first presentation even if this is at the time of delivery.

HIV positive women should have a CD4 count done to decide on PMTCT strategy.

ANTIRETROVIRAL THERAPY and PROPHYLAXIS

-CD4≥350 cells/ml -Daily AZT for the mother beginning 14 weeks gestation till delivery

-CD4≤350 cells/ml -HAART plus Cotrimoxazole prophylaxis throughout pregnancy and breast feeding. 

Obstetric factors that increase the risk for MTC transmission 

-Amniocentesis and amnioscopy

-Premature rupture of membranes and Preterm labour

-Sexually transmitted infections during pregnancy

-Antepartum haemorrhage

-Malaria in pregnancy

Management

-Treatment of anaemia with haematinics

-Screening and treatment of STI and lower genital tract infections such as syphilis, candidiasis, trichomoniasis, Bacterial vaginosis

-Close monitoring for IUGR

-Avoidance of invasive obstetric procedures( eg amniocentesis, external cephalic version)

-Nutritional counselling and supplementation

INTRAPARTUM MANAGEMENT

-Universal Precautions since not all parturients have known HIV status:

-Double Gloving

-Eye protection during pelvic assessment and delivery procedures

-Delay amniotomy till at least 6cm dilatation

-Avoid invasive monitoring( foetal scalp electrodes, foetal blood sampling)

-Avoid instrumental delivery unless absolutely necessary to safeguard the foetus

Labour and Delivery

Mothers with CD4 counts ≤350 cell/ml should be on HAART. 

Mothers with CD4>350cell/ml:

MOTHER: Single dose Nevirapine 200mg at onset of labour

• AZT +3TC during labour and delivery
• AZT +3TC 7 days postpartum to the mother

POSTPARTUM

-For mothers who do not need ARV for their own health, breast feeding infants should receive Nevirapine daily in increasing weight-based doses from birth until one week after exposure to all breast milk has ended.

-In non breast feeding infants, daily administration of AZT or Nevirapine from birth untill 6 weeks of age.

For all HIV positive mothers DUAL contraception of an effective hormonal or non hormonal  method  plus a Barrier method (male or female condom) is strongly recommended during breast feeding and long-term.

Details on different PMTCT scenarios and how to manage them can be obtained from the National PMTCT guidelines document which is updated regularly.

When the woman arrives you must decide whether she is in labour or not. Usually she will have regular painful uterine contractions, 3 in 10 mins with a show or ruptured membranes and associated cervical changes.

Management of labour in latent phase: 

• If on admission she is having labour pains BUT cervix is still long and closed, this could be early labour or false labour.
• Repeat vaginal examination after four hours.
• If progress is normal there is no need to worry
• If contracting but there is no cervical change she could be having prolonged latent phase. Perform ARM and augment with oxytocin. In some cases Registrar may decide to ripen the cervix first.

Start a partograph for every patient admitted in labour with zero time being time of admission.

Progress of labour

Cervical effacement is the assessment of the length of the cervical canal as length in cms and not percentage.

Cervical dilation is plotted as an “X” on the partograph.

The strength of contractions is graded as: mild or weak (<20 sec)/ moderate or fairly strong (20-40sec) and/ strong (>40 sec).

Draw in the ALERT LINE AND ACTION LINE if not already done.

Progress of labour must be assessed every FOUR hours if uncomplicated and every two hours if there are problems or labour has crossed the alert line.

Remember that there may be satisfactory cervical dilation with increasing caput and moulding and no descent of the presenting part- this may be an indication of cephalo- pelvic disproportion (CPD).

Mark the position of the head with reference to the posterior fontanelle or position of the breech with reference to the sacrum.

Sign legibly every vaginal examination and mark on the partograph the time for the next VE. Also indicate whether that VE should be by midwife or doctor.

Monitor maternal condition

Watch pulse, BP, temperature and urine.

Monitor fetal condition

Fetal heart rate: record fetal rate every half hour and more frequently if abnormal.

Liquor: if the membranes are intact write “I” in the appropriate column, if membranes have ruptured and the liquor is clear write “C”, if the liquor is meconium stained write “M”

Moulding: both occipito-parietal and parieto-parietal moulding should be recorded each time a vaginal examination is performed. Record as +, ++ or +++.

Caput: this is also noted each time a VE is performed and recorded as +, ++ or +++.

Poor progress of labour (prolonged labour) in active stage:

Commence antibiotics if membranes have been ruptured for more than 12 hours.

Ensure adequate hydration- put up a litre of Ringers lactate.

ARM if this has not been performed. 

Empty bladder if full.

Assess the cause of the poor progress and manage accordingly:

Inefficient uterine contractions:

Unless there is obvious CPD, always assume this is the primary cause. Contractions may be weak and short lasting or may feel strong but are ineffective (incoordinate contractions), typically seen in primigravida.

If there are no contraindications start Oxytocin infusion, give adequate analgesia, and review progress 2 hourly. 

Use the low dose oxytocin (1-4iu)

Malposition of the head:

Occipito posterior position:

This is the commonest cause of prolonged labour especially in primigravida.

Stimulate contractions to encourage rotation into occipito anterior position for delivery to occur in occupito-posterior position or face to pubis.

Give pethidine to avoid pushing before full dilatation.

Cervical dystocia:

There is no evidence of CPD but the cervix fails to dilate despite good contractions and trial use of oxytocin.

Deliver by caesarean section:

• All women should dilate at a minimum rate of 1 cm per hour and should be delivered within 6 hrs. of having crossed the action line. Later than this is associated with increased perinatal mortality.

Management of second stage of labour

Listen to the fetal heart after every second contraction.

Duration of the second stage is timed from when the patient starts pushing and must be noted. 

Second stage should not last more than 30 mins in primigravida and more than 20 mins in multigravida.

Active Management of the Third Stage of Labour

This consists of

• Uterotonic IM on delivery of the anterior shoulder: Oxytocin 5IU or Syntometrine 5IU/0.5mg (Oxytocin 5IU,Ergometrine 0.5mg).
• If not available, use Cytotec  200mcg PR
• Controlled cord traction
• Uterine massage

Perform caesarean section if:

-CPD: head 2/5 th above brim with 3+ of moulding or 3/5 the above with any moulding.

-Brow or mento posterior face,

-High breech

-Severe fetal distress

Perform Vacuum delivery if:

• There is no CPD
• Ensure there are good contractions; may need to put up a drip and start oxytocin.
• Vacuum delivery either in labour ward or trial of vacuum in theatre if suspect mild CPD.

Antenatal education is a vital part of preparing women for the pain of labour. Less medication is used if patient prepared psychologically for childbirth experience. Always individualize patient treatment. Know the pharmacology of the drug you intend to administer i.e. limitations, dangers, contraindications & advantages. All analgesics given to the mother will cross the placenta.

METHODS Non-medical/Psychological/ Natural Childbirth

• Educate the patient regarding: experiences of labor & delivery in order to prepare them for natural childbirth at antenatal classes.
• Relaxation techniques (e.g.-breathing), showers and massage- help patients cope with pain from uterine contractions.
• The presence of a birth attendant/ partner/ maintenance of mobility- help women cope with labour pain 

Systemic pharmacologic intervention

Either narcotics or sedatives with anti-emetic (prochlorperazine/stemetil12.5mg or promethazine/phenergan 25mg)  during the 1^st stage of labour relax patients & decrease pain. eg. Pethidine (1-2mg/kg body weight q3-4 hourly, or 50-100mg q3-4h). 

Note: 

• Morphine (0.10-0.15mg/kg 4 to 6-hourly) may be used early in labor if pethidine is not available. 
• In patients with severe pre-eclampsia, use of morphine is preferred as Pethidine is unsuitable, since its primary metabolite norpethidine has convulsant properties.

Disadvantages: 

• Analgesic effect is small, many patients feel sedated, confused and out of control 
• Can cause hypotension , nausea & vomiting 
• Respiratory depression in mother and increased risk of aspiration
• Sedatives cross the placenta and depress the neonate if used close to delivery (within 2 hours of childbirth).

Antidote to opiates:  Naloxone 0.01mg/kg I.M.

Inhalational Analgesia

Entonox is an equal mixture of nitrous oxide and oxygen (50% N₂O and 50% Oxygen). It is  used for pain relief for late1^st & 2^nd stages of labour, crowning of the head, ARM and during initiation of epidural analgesia.

Administration: The patient needs to breathe in as soon as she feels a contraction is starting and take two to three puffs with each contraction. It is good in early labour and during the latter part of first stage labour

Advantages:

• Safe (minimal maternal/neonatal side effects),
• Simple/easy to use, 
• Quick onset & short duration of effect  ? Is patient-controlled. 
• It is more effective than pethidine 

Disadvantages:

• Mild analgesic effect, 
• May cause nausea, hyperventilation and light-headedness; 
• Use in early labor may result in maternal hyperventilation, dizziness, tetany and fetal hypoxia.

Epidural Analgesia

This is the most ideal analgesic in labour but should be used only when there is adequate nursing staff to monitor the woman and fetal heart rate, facilities for cardio-pulmonary resuscitation and oxygen & suction should be immediately be available. Its main indication is effective pain relief in labour, e.g. in  dysfunctional labour, hypertension, multiple pregnancy, instrumental/assisted vaginal breech births. 

Contra-indications:

Absolute

• Hypovolemia eg in massive antepartum haemorrhage, 
• Anticoagulant therapy( except low-dose heparin)/ bleeding   disorder, 
• Local/systemic sepsis or 
• Tumour at injection site, 
• Anomalies or active neurological disease,  ? Intracranial space-occupying lesion,  ? Lack of trained staff.

Relative

• Patient refusal 
• Morbid obesity             ? Extensive back surgery.

Potential Problems with Epidural Analgesia

         ? Prolonged labour if block too extensive. Treatment is by oxytocin infusion.

• Accidental I.V. injection of local anesthetic 
• Toxicity: delirium, convulsions, acidosis, arrhythmia & cardiac arrest or death.
• Maternal hypotension if block extends unintentionally above T10 level.
• Spinal tap result in severe acute headache and occasionally chronic headaches ? Local anaesthetic into sub-arachnoid space result in spinal block: total spinal results ? Fetal heart rate decelerations secondary to maternal hypotension.
• Urinary retention, poor mobility.

Local Analgesia

• 1% Lignocaine (preferably with adrenaline): infiltrate perineum for patients who require episiotomies, repair of  vaginal, perineal, periurethral lacerations and episiotomies. 
• Toxic dose of lignocaine: 5mg/kg-plain lignocaine or 7mg/kg if lignocaine with adrenaline

Caution

1. Avoid intravascular injection. 
2. Infiltration in or near an area if inflammation (rapid systemic absorption). 

Other methods

Pudendal Nerve block:  Local anaesthetic injected bilaterally as it passes just medial to the ischial spine. It is used for pain relief during the  2^nd stage of labour.

Informed consent

• Explain in detail what procedure will be done and the risks and benefits based on local or global evidence.
• Allow the woman to make a decision and respect her views

Consent for minors/ vulnerable women/ mentally incapacitated women

• Pregnant Minors are regarded as emancipated adults and can consent for the sake of their baby to whom they are guardian.
• Vulnerable women and women who are mentally incapacitated or unconscious a senior health care giver can consent on their behalf  

Please take time to explain to the woman why she needs an operation and what that exactly means. Include all the probable outcomes and side effects of the procedure and implications for future pregnancy. Informed consent is important particularly in subsequent pregnancy care. Pregnant minors are allowed to give consent for all procedures including caesarean section and care for their newborn. 

Preoperative preparation

• FBC for all pregnant women going for a caesarean section.  Group and retain and urea and electrolytes should be done when indicated. 
• Shave and pass an indwelling catheter to empty the bladder. 
• Give antacids – sodium citrate 15ml stat prior to caesarean section
• Women should be offered prophylactic antibiotics e.g. single dose of Cephalosporin or ampicillin to reduce the risk of postoperative infections such as endometritis, urinary tract infection and wound infection.
  • Elective-Rocephin 1g iv stat or Ampicillin 1g iv stat
  • Emergency-Ampicillin or Rocephin 1g iv stat then amoxyl  and metro x 5/7
• Recheck presence of fetal heart prior to operation.
• Preferably if it was an uncomplicated procedure remove catheter in theatre. If urine was blood stained or if there was obstructed labour, leave catheter in situ for 7-10 days.
• If there were any problems, pre, intra or post operatively, send patient for close observation.
• Documentation of the intraoperative procedure must be done clearly especially if extra procedures were performed e.g. bladder repair
• Women who are recovering well and who do not have complications after CS can eat and drink when they feel hungry or thirsty.
• Women who are recovering well and do not have complications can be discharged after 3-4 days.

Cord presentation  - umbilical cord lies in front of the presenting part with the membranes still intact.

Cord prolapse– as above but with membranes ruptured.

Risk factors:

• High head (if membranes rupture with high head- ARM should never be performed with a high head)
• Preterm labour,
• Malpresentations  (complete or footling breech, transverse lie),
• Polyhydramnios
• Multiple pregnancy.

Clinically

• with cord presentation the cord is felt during vaginal examination while membranes are intact.
• With cord prolapse membranes have already been rupture
• Where there are predisposing factors, do a vaginal examination as soon as membranes rupture.

Suspect cord prolapse if fetal heart rate is abnormal for no apparent reason.

Management:

• Call for help
• Once confirmed do not touch the cord because it can cause spasm of the vessels
• Listen to fetal heart with sonicaid

Fetal heart present:

• If cord is lying outside the vagina, gently replace it into the vagina to keep it warm and prevent spasm of the vessels
• Relieve pressure off the cord
• Position the woman with her buttocks higher than her shoulders, causing the foetus to gravitate towards the diaphragm (knee chest position) until the woman has delivered.
• This can be achieved also by filling bladder with 500 mls saline.
  • if during first stage: give oxygen by mask and prepare for immediate caesarean section
  • if second stage:   if head is low get her to push or perform a vacuum. o If head high perform a caesarean section
• Prior to performing a caesarean section, listen to the heart rate to ensure that the baby is still alive. 

Foetus heart absent:

Allow labour to continue and deliver vaginally.

We should rely on fetal heart rate patterns picked up with the Pinard stethoscope or CTG. If there is high risk of fetal distress (thick MSL, PIH, prolonged labour etc) assess fetal heart rate using the hand held Doppler or CTG if at all in doubt.

Fetal HR patterns that suggest fetal distress include:

• A heart rate below 110 or greater than 160 beats per minute 
• Early and late decelerations particularly in the presence of abnormal baseline
• Persistent bradycardia (<100beats/min) in a woman previously known to have had a normal fetal heart rate 

Management

This is aimed at intrauterine resuscitation followed by Delivery

Intrauterine resuscitation measures

• Position   Turn patient to the left lateral position 
• Oxygen     Give 100% oxygen by mask or nasal prongs
• Rehydration Check hydration status and rehydrate appropriately
• Contractions If on oxytocin infusion, discontinue If she is having frequent/and or very strong  contractions consider giving a tocolytic, 10ug Hexaprenaline ivi over 5 mins or nifedipine 30mg orally
• Diagnosis Look for possible causes of distress and remedy if possible. The possible causes are cord prolapse, hypotension from antepartum haemorrhage, uterine rupture, sudden rise in blood pressure 

Delivery (Definitive Management)  

• Discuss with registrar
• If fully dilated expedite delivery by vacuum extraction 
• If not fully dilated consider caesarean section

If HR returns to normal observe very carefully, keep patient on her side, prepare for caesarean section and discuss with registrar

After delivery of the baby and placenta, the vagina and perineum should be carefully inspected to determine if any injury has occurred during the delivery, especially if there is postpartum bleeding in the presence of a well contracted uterus. Adequate examination and repair of the upper vagina and cervix requires adequate light and equipment.

Vaginal lacerations

• First degree involves only vaginal and perineal skin
• Second degree involves skin and perineal muscle
• Third degree involves extension of above to involve the anal sphincters
• Fourth degree involves  anal sphincters  and rectal mucosa as well

Repair

• Superficial lacerations do not require suturing unless there is an active bleeder.
• Second degree tears require immediate suturing as delay results in unnecessary blood loss.
• Infiltrate the area with 10ml 1% Lignocaine.
  • Identify the upper end of the tear and close the vaginal tissue with a continuous stitch, using vicryl  or Dexon.
  • Align the hymenal ring.
  • Before suturing the muscles identify and ligate any major bleeding vessels
  • The muscles are apposed with interrupted sutures.
  • The perineal skin is then closed, preferably with a subcuticular suture.
  • Ensure you have not left any vaginal pack at the end.
• Third and fourth degree tears should be sutured by an experienced doctor, under regional or general anaesthesia. The rectal mucosa and muscle wall are repaired in two layers, using fine cagut sutures. The sphincter ends are identified and drawn up with tissue forceps to allow firm suturing. The rest of the wound is repaired in the usual way.
• Antibiotics – Always give prophylactic antibiotics to prevent wound sepsis
• Laxatives – May give to women with 2^nd-3^rd tears to facilitate defecation
• Pelvic floor exercises
• Review at 6 weeks

Cervical tear

• They should be sutured if bleeding or if more than 2-3 cm long, even if not bleeding.
• They can be associated with rupture of the uterine vessels and broad ligament haematoma.
• The genital tract must be explored under GA. 
• Large retractors are required and the cervix grasped with sponge holders and drawn down and to the side. 
• Wide, deep, interrupted catgut sutures are inserted through the whole thickness of the cervix.

Introduction

Presence of meconium may be a sign of fetal distress. It is therefore important to detect this and be alert before the actual delivery. Presence of thick meconium staining of liquor is an indication for transfer of the patient from the Clinic to a referral Hospital.

Management

• At the referral hospital, a careful history and examination must be conducted to find the cause, (fetal distress, breech presentation, postmaturity) the stage of labour and the status of the fetal heart rate. 
• Listen to the fetal heart rate very carefully on arrival or at first detection for any fetal heart rate abnormality. 
• Use a Doppler if in doubt and listen before, during a contraction and immediately after. 
• Call the Registrar in admission room to assess if there is any fetal heart rate abnormality.
• If fetal heart rate is normal, admit to labour ward and instruct for careful fetal heart rate monitoring. 
• If continuous  Electronic Fetal Monitoiring is available, its use is advisable and good practice in the presence of thick green/black meconium. 
• Oxytocin is only used after you have ensured fetal heart rate is normal with consent of a senior on call. 
• In the presence of thick meconium and very early labour it is good practice to opt for c/s
• Before delivery ensure you have a working suction machine ready by the bed side and that a wide bore suction catheter and working laryngoscope is available. It might be necessary to call the paediatric SRMO to assist with resuscitation. 
• Suctioning of the nasopharynx and oropharynx prior to birth of the shoulders and trunk should not be carried out.
• The upper airways should only be suctioned if the baby has thick or tenacious meconium present in the oropharynx. 
• If the baby has depressed vital signs, laryngoscopy and suction under direct vision should be carried out by a healthcare professional trained in advanced neonatal life support. 
• If there is thick meconium past the vocal cords, you will need to intubate and pass a suction tube through. As you suck withdraw the ET tube to suck out the thick meconium and repeat this until there is no more meconium.
• It is important to clear all meconium from the bronchial tree BEFORE ventilating.
• It is also a good idea to empty the stomach of any meconium.
• If the baby is showing signs of asphyxia proceed with the method of resuscitation as described elsewhere.

A baby born in the presence of  significant MSL should be observed for at least 12hrs for:

• General wellbeing 
• Chest movements and nasal flare 
• Skin colour including perfusion, by testing capillary refill
• Feeding
• Muscle tone
• Temperature 
• Heart rate and respiration

Progress of labour has been arrested by mechanical factors, usually cephalo- pelvic disproportion.

Clinical Presentation

• The woman appears dehydrated and toxic and may be pyrexial.
• There may be frequent strong contractions in multiparous women, or they may have ceased if uterus has ruptured. In primigravidae contractions cease when there is obstruction.
• There may be a constriction ring (Bandle’s ring) as the lower segment becomes thin and oedematous whilst the upper segment thickens from increasing contractions. On abdominal examination the presenting part is three fifths or more above the brim
• Fetal heart may be absent or there is feat distress.
• There is meconium or foul smelling liquor.
• Vulva and vagina may be oedematous.
• There is large caput with excessive moulding and a high presenting part.
• The presenting part may be poorly applied to cervix
• There may be a prolapsed arm.
• Urine is concentrated on catheterization.

 Management:

• Commence on intravenous broad spectrum antibiotics.
• Give intravenous fluids
• Blood investigations (FBC , U&Es , et cetera)
• Plan delivery, mode of delivery will depend on state of the mother and the baby. Usually this is by caesarean section and needs to be performed by the most experienced person available as soon as possible.
• Consultant may occasionally perform Symphisiotomy
• Catheterization for 7 -14 days

Shoulder dystocia is defined as failure of delivery of the shoulders after the delivery of the fetal head. 

 Factors associated with shoulder dystocia

Pre-labour

• Previous shoulder dystocia
• Macrosomia
• Diabetes mellitus
• Maternal body mass index > 30 kg/m2
• Induction of labour

Intrapartum

• Prolonged first stage of labour
• Secondary arrest
• Prolonged second stage of labour
• Oxytocin augmentation
• Assisted vaginal delivery

 Recognition 

The skilled birth attendant should routinely observe for the following signs which may indicate that there is shoulder dystocia:

• Failure of the head to advance with crowning
• Difficulty with delivery of the face and chin
• The head remaining tightly applied to the vulva or even retracting. Failure of restitution of the fetal head
• Failure of the shoulders to descend. 

 Management: 

This is an emergency and when called, the attendant must be able to go through the various stages to deliver the baby in an orderly manner without panicking. We have 5-7 minutes to deliver the baby to avoid serious damage. Care must be taken not to twist the neck and as far as possible avoid excessive traction on the head to avoid damage to the brachial plexus.

• Immediately after recognition of shoulder dystocia, extra help should be called from an experienced midwife or  doctor
• Maternal pushing should be discouraged, as this may lead to further impaction of the shoulders, thereby exacerbating the situation
• The woman should be manoeuvred to bring the buttocks to the edge of the bed as possible
• If the perineum is tight, perform a large episiotomy and apply gentle traction.
• Fundal pressure should not be employed because it is associated with an unacceptably high neonatal complication rate and may result in uterine rupture
• Get the patient into an exaggerated flexion and abduction of the hips, positioning the maternal thighs on her abdomen (McRoberts’ manoeuvre).
• The McRoberts’ manoeuvre is the single most effective intervention with reported success rates as high as 90% and a low rate of complication and hence should be performed first. It straightens the lumbo-sacral angle, rotates the maternal pelvis cephalad and is associated with an increase in uterine pressure and amplitude of contractions.
• If this fails, get the assistant to apply firm suprapubic pressure to push shoulders into the pelvis. Ask the assistant to use the heel of the hands to push the shoulder down and under the symphysis pubis from above. Suprapubic pressure reduces the bisacromial diameter and rotates the anterior shoulder into the oblique pelvic diameter. The shoulder is then free to slip underneath the symphysis pubis with the aid of routine traction

 Second  Line Manoeuvres

If these simple measures (the McRoberts’ manoeuvre and suprapubic pressure) fail, then internal manipulation will be applied.  Apply the following internal procedures in order:

• Hook two fingers into the anterior axilla and rotate the shoulders forwards under the pubic arch or
• Deliver the posterior shoulder by drawing the head in an upward curving direction while the assistant applies suprapubic pressure on the anterior shoulder or,
• Insert four fingers behind the posterior shoulder and try to rotate it into the hollow of the sacrum, or
• Slide your hand along the posterior vaginal wall and try to rotate shoulders into oblique position or rotate 180 degrees to bring the posterior shoulder anterior, or
• Deliver the posterior arm- the whole hand is inserted into the hollow of the sacrum flex the elbow and try to bring down the posterior arm by sliding the arm along the body

Third-line manoeuvres

• Requires careful consideration to avoid unnecessary maternal morbidity and mortality.
• These include o Turning the women on all fours(knee-elbow position) and repeating all the  internal measures
  • Cleidotomy (bending the clavicle with a finger or surgical division),  
  • Symphysiotomy (dividing the symphyseal ligament)

• After delivery, the birth attendants should be alert to the possibility of postpartum haemorrhage and third- and fourth-degree perineal tears. 
• In cases of macrosomia, always check the mother for diabetes in the puerperium and in subsequent pregnancies.

Indications include:

• Prolonged second stage – poor maternal effort, malposition or heavy sedation. Do not allow a woman to bear down for longer than 20mins in multigravida and longer than 30mins in primigravid women. Assist in order to minimise fetal distress
• To avoid maternal effort – cardiac, severe hypertension
• Fetal distress in second stage with head low
• Cord prolapse in second stage and low head

 Before attempting a vacuum delivery:

• Ensure presentation is suitable – must be cephalic vertex
• Ensure there is no Cephalo-pelvic disproportion-head must be no  more than 1/5^th above brim with minimal moulding or lower with moulding.
• Cervix is at least 8cms dilated in a multiparous and fully dilated in primiparous woman.
• Position of the head is known
• Uterine contractions are strong- if poor, start oxytocin
• Empty bladder if full

 DO NOT PERFORM EPISIOTOMY UNLESS IT IS ABSOLUTELY ESSENTIAL

Procedure

• Select the largest size cup that will fit well
• Connect the cup and test for vacuum and ensure there are no leaks
• Apply the cup onto the scalp over and as close as possible to the occiput. Before applying vacuum ensure there is no vaginal tissue or cervix caught between the cup and the scalp. Apply vacuum up to 0.8kg/cm2. While controlling cup by using index and ring finger over head and thumb over cup, pull during each contraction while the woman pushes. Try and get at least three good pulls with each contraction and with each pull there must be descent of the head. When pulling keep the tube at 90 degrees to the cup.
• If the cup slips off more than once or if there is no descent abandon procedure and call Registrar.
• Ensure someone is listening to the fetal heart after each contraction.
• If there is suspicion that there may be difficulty with the vacuum or suspicious Cephalo-pelvic dispropotion then perform trial of vacuum in theatre so that caesarean section can be performed rapidly. The registrar must only perform trial of vacuum.

These patients have a high risk of Post partum Hemorrhage and therefore give iv oxytocin after delivery

Introduction

As the baby’s head is crowning, get ready to support the perineum. As the head is born wipe out excess mucous but handle baby gently. Wait for the next contraction to deliver the body and lay the baby on to the mother’s abdomen and note time of birth.

If there was no meconium and the mucus is clear there should be no need for suctioning.

Most healthy babies will cry and breathe spontaneously at birth.  Leave these babies alone unless there was meconium staining of the amniotic fluid.

Asphyxia 

Is the failure to initiate and sustain respiration at birth. This could be due to intrauterine hypoxia (eclampsia or after general anaesthesia, hypertension, haemorrhage, hypertonic uterine contractions) or from birth asphyxia (obstruction of the airway by mucus plug, blood or meconium) or from traumatic cerebral damage from a difficult delivery.

Although birth asphyxia may be anticipated there are times when the baby is born in an asphyxiated condition without any forewarning. Therefore resuscitation equipment must always be available and in working order and all attendants must be familiar with its use.

Assessment

• Pink- Dry and Wrap
• Breathing Regularly,Heart rate >100beats/minute- Give baby to the mother

• Blue,Breathing inadequately ,Heart rate- Dry and Wrap.Open Airway, Inflation breaths

•  

  Blue or white ,Not breathing,Heart rate <60beats/minute-Dry and wrap, Open airway, Inflation breaths ,Reassess

Management:

Warmth- hypothermia worsens hypoxia. Remove wet towels, cover body and head with pre warmed blanket leaving the chest exposed.

Airway

• Clear the airway – this is usually only necessary if meconium is present; suck under direct vision.
• Position the head in the neutral position to open the airway. Overextension or flexion will collapse the pharyngeal airway. A towel folded 2-3cm thickness placed under the shoulders will help to achieve the correct position
• Very gently suction of the oropharynx or nostril ONLY using a soft suction catheter may be used. Deep suction is dangerous and should not be used – it can cause bradycardia and spasm of the larynx

Breathing

• Stimulation – gentle stimulation by drying body is often all that is required; oxygen at low flow directed at the face will also stimulate a gasp reflex.
• Place the mask (attached to the bag) firmly over the newborn’s mouth, chin and nose, to from a seal between the mask and the newborn’s face
• Using bag and mask,give five inflation breaths, each 2-3seconds
• Reassess the heart rate after the first 5breaths: an increasing heart rate or a heart rate maintained at more than 100beats/minutes is a sign of adequate ventilation
• Ventilation should be continued at 30 – 40 breaths/minute
• If the colour looks good but the baby fails to breathe, give neonatal Naxolene if mother had been given Pethidine and continue ventilating for 2-3 minutes and the baby should start to breathe spontaneously.

Circulation

• If there is no heartbeat or the heartbeat is <60beats/ minute, even when the chest is being ventilated, give chest compression. However, the most common reason for the heart rate remaining low is that successful ventilation has not been achieved
• The best way to give a cardiac message is to encircle the baby’s chest with two hands so that the thumbs meet on the sternum below the line between the nipples. Compress the chest by one – third of its depth – three times for each inflation
• Once the heart rate is above 60/minute and rising, chest compression can be discontinued

If the baby’s breathing is normal (30 – 60 breaths/minute) and there is no indreawing of the chest and no grunting

• Put in skin – skin contact with mother
• Observe breathing at frequent intervals
• Measure the newborn’s temperature and re-warm if temperature is less than 36ºC
• Keep in skin to skin contact with mother
• Encourage mother to begin breastfeeding
• Keep the baby under observation until she has been stable for at least 6hours
• Explain what happened to the mother

If there is no gasping or breathing at all after 20minutes of ventilation or gasping but no breathing after 30 minutes of ventilation, stop ventilating.

Note: Do not in any case

• Slap, blow on or pour cold water on the baby
• Hold the baby upside down
• Routinely suction the mouth and nose of a well baby
• Use heavy suctioning of the back of the throat of any baby
• Give injections of respiratory stimulants or routine sodium bicarbonate injections

                                                                                                                                         Naloxone – antidote for maternal narcotic drugs administration. It does not depress respiration itself and therefore does not do any harm. The dose is 100 micrograms per kg- neonatal naloxone 1-2mls; ie 0.5mls for every tiny baby, I ml for a small baby, 1.5mls for an average size baby and 2mls for a big baby. The dose can be repeated safely.

Bleeding from the genital tract at any time following the birth of the baby up to 6 weeks after delivery. Post Partum Hemmorrhage is a major obstetric emergency contributing 25% maternal mortality in Zimbabwe.

IT IS THE EFFECT OF BLOOD LOSS RATHER THAN JUST THE AMOUNT OF BLOOD LOOS THAT MATTERS.

Call for help with blood loss over 500 mls even without systemic signs and also with blood loss of less than 500 mls if there is deterioration in the woman’s haemodynamic status.

Causes

• Atonic uterus: bleeding usually begins a few minutes after birth and tends to come in gushes as blood is expelled as a contraction occurs. The fundus may rise above the level of the umbilicus as the uterus fills up with blood, and the uterus will feel boggy.
• Retained placenta/ products of conception
• Genital tract trauma: the bleeding starts immediately after the baby is born and the flow is continuous, often a heavy trickle. The uterus is well contracted.
• Inversion of the uterus
• Disseminated intravascular coagulopathy

Management:

• Call for help
• Assess general condition
• Resuscitate the patient
• Find the cause
• Stop the bleeding
• Prevent further bleeding

Management- Placenta Delivered

• Rub fundus gently to stimulate a contraction. Give 5 units oxytocin preferably intravenously. May give ergometrine 0.5milligrams IM.
• Take blood for haemoglobin and cross match
• Put up an iv line with Normal saline or Ringers Lactate.
• If in shock resuscitate immediately. Elevate the foot of the bed and run in Saline or Ringers lactate fast until blood pressure is at least 100 mm Hg systolic.
  • Use haemaccel and blood
  • If bed side clotting time  abnormal, give 4 units of Fresh Frozen Plasma
• Keep uterus well-contracted with 20-40 units of oxytocin infusion.
• Empty bladder
• Rectal misoprostol 800 micrograms-1000mg stat.
• Bimanual compression of the placental site - useful while waiting for the uterus to contract. Insert sterile gloved right hand into the vagina like a cone, and the flat part of the closed fist is placed into the anterior vaginal fornix and against the anterior uterine wall. The left hand is placed behind the uterus abdominally with the fingers directed towards the cervix. The uterus is brought forwards and with the palm of the left hand it is pressed onto the fist in the vagina. This must be maintained until the uterus contracts.
• Examine the placenta to ensure placenta and membranes are complete.
• With a persistently atonic uterus, the patient may require laparatomy with Compression sutures (e.g. B-Lynch sutures) or Hysterectomy

Management- Placenta NOT delivered

• Principles of management are initially the same.
• FBC , U&Es , Cross-match
• Perform a vaginal examination in case placenta is felt protruding through the cervix, in which case it may be grasped and gently withdrawn.
• Perform manual removal of the placenta in labour ward, if she has just delivered this can be performed using iv pethidine and diazepam, if not then arrange to do this in theatre under General Anaesthesia.
• Suspect accreta, incretta or percretta especially in women with previous scars. After removal commence her on antibiotics and treat her for atonic Post partum hemorrhage.Keep uterus well contracted with 20 – 40 units oxytocin infusion. Closely observe until stable and bleeding settled.

Management- Traumatic PPH

• Initial management is the same- ensure general condition stable and resuscitate if shocked
• In order to identify the source of the bleeding, the mother is placed in a lithotomy position under good light. External injuries will be identified easily and can be repaired. Internal injuries will be seen with a Sims speculum examination. Suture bleeding sites to stop bleeding.
• If you suspect uterine rupture perform laparotomy.

Loss of a pregnancy before it reaches viability (WHO definition 22 weeks or 500g). At least 15% of confirmed pregnancies end up in miscarriage, mostly in the first 12 weeks.

Clinical types:

Threatened miscarriage: 

• there is slight fresh vaginal bleeding usually in the first three months of pregnancy
•  there are usually no clots.
• Pain is not a feature although there may be slight lower abdominal pain or backach
• On examination the internal os of the cervix is closed and the size of the uterus corresponds to gestational age by dates.

Management:

1. • Advise to rest at home and not have sexual intercourse for up to 2 weeks after the bleeding has stopped. No medication is helpful. Can give a sedative if patient very anxious. An USS can be done to confirm fetal viability.

Inevitable miscarriage:

• bleeding is now more severe with clots but no products of conception have been seen
• The uterus is contracting to expel the conceptus and therefore there will be colicky lower abdominal pain
• On examination the cervix will be open and no products of conception are felt as yet.

Management:

• • Evacuation of the uterus as for incomplete abortion if <16 weeks
  • If the  size of the uterus is >16 weeks, use oxytocin infusion to expel the fetus before evacuation

Incomplete miscarriage:

• bleeding is usually quite heavy and is associated with clots and products of conception which she will say look like fleshy material
• The pain is marked and colicky
• On examination the cervix is open with products of conception protruding.
• Incomplete miscarriage may be complicated by:
• • Shock: - there may be varying degrees of shock depending on the amount of blood lost.
  • Sepsis: - often with unsafe abortion and sometimes even without, sepsis may occur. There will be fever and lower abdominal tenderness. The degree of shock is often more than the amount of blood loss would suggest.

Management:

• • Resuscitate with intravenous fluids if the patient is in shock.
  • Give oxytocin 5 IU or ergometrine 0.5mg im if evacuation of uterus is not immediately possible

• Commence prophylactic antibiotics if not obviously septic or full high dose triple antibiotic treatment if obviously septic and evacuate the uterus after administration of appropriate antibiotics for at least 12 hours.
• If cannot perform evacuation immediately and she is bleeding heavily, remove products of conception or placental tissue digitally or with sponge holding forceps.

Complete miscarriage

• history and findings are as above but all products have been expelled.
• This should only really be diagnosed if a nurse/doctor has witnessed expulsion of a complete gestational sac or a foetus with a complete placenta
• Bleeding has now settled and there is no evidence of any complications. 
• If an USS is readily available, it can also be used to confirm the diagnosis
•  Management:
• • Antibiotics and contraceptives can be prescribed after adequate counselling

???????Missed miscarriage:

• bleeding occurs between the gestational sac and the uterine wall and the foetus dies but does not get expelled from the uterus.
• There may be slight vaginal bleeding or just brown discharge.
• She has no feelings of pregnancy any longer.
• The diagnosis is confirmed by scan

Management:

• Treatment is by performing manual vacuum aspiration. If the cervix is tightly closed       misoprostol can be administered prior to the evacuation to soften the cervix

Bartholin’s glands are bilateral mucus secreting structures situated at the opening of the vagina. They are usually not palpable. An abscess or cyst developing in the duct of the Bartholin’s gland is situated at the junction between the anterior 2/3 and the posterior 1/3 of the labia.

Abscess:

Clinically: presents with pain, redness, tenderness and fluctuation in addition to the vulval swelling.

Treatment: - is by drainage and marsupialisation of the abscess.

Cyst:

A Bartholin’s duct cyst is treated by marsupialisation. If the cyst recurs, it is usually best to remove the cyst and the gland. Marsupialisation

After local anaesthesia:-

• Make an elliptical incision in the vaginal mucosa over the abscess
• Cut into the abscess  wall to drain pus
• Irrigate the abscess cavity
• Suture the cut edges of the abscess wall to the surrounding mucosa with interrupted absorbable sutures so that the base of the abscess is exposed (exteriorized)

Introduction

This is a result of the fertilised ovum implanting outside the uterine cavity. The commonest site is the ampullary portion of the fallopian tube (~72%), followed by isthmic, fimbrial and cornual portions in that order.An ectopic pregnancy can also occur in the ovary, abdominal cavity or the cervix. Most will cause catastrophic intra-abdominal haemorrhage due to rupture of the fallopian tube, a significant cause of maternal mortality. Pelvic inflammatory disease is the commonest underlying cause of the associated tubal blockage. 

Risk Factors

• Previous ectopic pregnancy.
• History of tubal surgery.
• Pelvic infection.
• Pregnancy following sterilization.
• Pregnancy occurring in presence of IUCD.
• Conception following ovulation stimulation (may result in heterotopic pregnancy which is very rare)

Diagnosis of ruptured ectopic pregnancy This will be made based on the following:

• A woman of reproductive age who develops abdominal pain, with or without abdominal distension, after a period of amenorrhoea usually less than 10 weeks.
• Pregnancy test may be positive.
• Severe abdominal pain may be associated with shoulder tip pain especially on lying down due to peritoneal blood irritating the diaphragm.
• There may or may not be a history of vaginal bleeding.

On examination:

• The patient will be pale and in shock
• Abdomen will be distended, with rebound tenderness and guarding. 
• On vaginal examination there will be marked tenderness on moving the cervix side to side and the cervix will be closed.
• Correct early diagnosis is important to reduce maternal mortality and morbidity. 

Unruptured Ectopic Pregnancy: 

• Abdominal pain may be mild with some vaginal bleeding as above. 
• Patients may have slight pallor and even low grade fever with tachycardia. 
• It is very difficult to feel an adnexal mass on bimanual palpation 

NB: There are several case reports in literature where patients have ruptured following an examination

• An ultrasound scan is usually indicated which often demonstrates an empty uterus. Depending on the skill of the sonographer, the number of ectopic pregnancies that can be seen on USS is small. Quantitative HCG in conjuction with USS may be helpful in some cases.

Differential diagnosis:

• PID 
• Acute appendicitis 
• Ovarian accidents (rupture or torsion of an ovarian cyst)
• Other causes of acute abdominal pain

Management:

• Patients with a diagnosis of ruptured ectopic pregnancy have continuous intraabdominal bleeding which requires immediate laparotomy and salpingectomy to halt the haemorrhage.
• Perform the basic ABCs of resuscitation 
• Put up two iv lines using wide bore canulae and run in Ringers Lactate fast to bring systolic blood pressure to at least 100mm Hg
• Take blood for haemoglobin estimation and X-match four units of blood
• If still shocked, may need to give Haemacel or fresh frozen plasma.
• In case of multi-gravida women discuss future plans and if she does not wish to have any more children discuss sterilisation
• At laparotomy after confirmation of tubal pregnancy the opposite tube is inspected first prior to definitive surgical procedure.
• Salpingotomy may be considered in the presence of one tube or where the contralateral tube appears damaged.

The majority of women can tolerate the procedure of MVA without analgesia if given adequate explanation and support. MVA is a vital tool in reducing bed occupancy as the major burden of emergency gynaecology work comes from miscarriages. Cervical preparation can be very useful as it reduces the pain experienced in those requiring cervical dilatation.

What is MVA?

• Hand-held syringe for uterine evacuation
• Locking valve/plunger creates vacuum
• Portable and reusable
• Vacuum equivalent to electric pump
• Efficacy same as electric vacuum (98%–99%)
• Used with semi-flexible plastic canula

Indications for MVA: 

• Most women with incomplete miscarriages are suitable for MVA. 
• Perform MVA if uterine size is 12 weeks or less by LMP and products are still in the uterus. 
• It can be performed with larger uteri if placenta and foetus have been expelled.
• If however on examination you see placental tissue or products sitting in the os you will not be able to perform MVA unless you first remove those with a sponge holding forceps.

Cervical Preparation: 

For patients whose cervices are closed and/or require dilatation, administer Misoprostol 400/600mcg (3 tablets) into the posterior vaginal fornix at least 2 hours before the procedure.

Analgesia:

It is often possible to perform MVA without any analgesia. If however you have an anxious patient, give 10mg diazepam half an hour before the procedure.  

Cervical Block Techniques:

Two methods:

i. Paracervical

ii. Intra-cervical -10-20 mls of 0.5% or 1% Lignocaine

• Spinal needle or needle extender useful

Systemic Analgesia

 1. may choose to use 100mg pethidine and 10mg diazepam prior to the procedure. 

2. Ibuprofen 800 mg orally 30-45 prior to procedure
3. Diclofenac is an effective alternative
4. Paracetamol 1000 mg orally 30-45 minutes prior to procedure if unable to take NSAIDs

Intra-operative prophylactic antibiotics: 

This is usually adequate to prevent any post evacuation infectious morbidity. Give metronidazole 1gram PR or 2 grams orally post-procedure or intravenously during evacuation.  

MVA Procedure

• Perform a vaginal examination to ascertain uterine size, dilation of cervix and to exclude any other pathology
• Select appropriate size syringe and canula. Generally for uterine size of greater than 6-8 weeks you will need a double valve syringe. The size of the canula depends on the dilation of the internal os and is usually 2mms smaller than the uterine size in weeks.
• Assemble the syringe, create the vacuum and leave it on the trolley
• Clean and drape the patient; insert Graves (Cuscos) speculum to make the cervix easily accessible. Clean the cervix and grasp it gently with the volsellum. If you are going to use a paracervical block give it at this point.
• Get the syringe and release valve to check vacuum has not been lost. Recharge the syringe. Insert the canula gently into the uterus, observing the no touch technique, (i.e. do not let the canula touch any part of the vagina while being introduced into the uterine cavity), until it goes through the cervix and touches the fundus of the uterus. The canula must fit snugly into the cervix; if very loose you may need a larger size. Withdraw the canula a little and attach the syringe with or without the adapter depending on the size of the canula.
• Release pinch valve and evacuate the contents by gently moving back and forth as well as rotating and see Retained Products Of Conception(RPOCS) being sucked into the syringe. You should see blood clots, RPOCs and bubbles in the canula.
• Do not remove the canula until the procedure is complete unless it gets blocked. If canula is blocked, close pinch valve and remove canula with syringe, unclog, establish vacuum and restart. If syringe is full, close pinch valve, detach syringe, empty it into kidney dish, and establish vacuum and restart.

NB: Never push plunger in while it is attached to canula and the canula is in the uterus due to risk of embolism.

• Continue until uterus is empty as evidenced by gritty sensation, red/pink foam with no tissue and uterus contracts and grasps the canula
• Close pinch valve, remove canula and syringe. Inspect RPOCs.

Answer any questions and rediscuss contraception. Please ensure that the patient leaves with some form of contraception if she has decided to use one. If she requests an injection or an implant make arrangements for her to get one. Sterilisation should also be booked there and then if she requests it.

• Advise not to have intercourse for two weeks, not to insert vaginal tampons/cotton wool.
• Discharge her on antibiotics:
  • • 100mg doxycycline BD for 5 days.
    • 400mg Metronidazole TDS for 5 days.
  • Advise her to return if heavy bleeding continues ,Foul smelling discharge, Fever
• • Consider a follow-up USS to confirm complete evacuation.

Definition

infection of the genital tract infection above the level of the internal os.

Introduction: 

Upper genital tract infection or PID is a common gynaecological emergency. It occurs both symptomatically and asymptomatically causing serious morbidity especially in young women. It is a significant public health concern as it is the commonest cause of tubal infertility and chronic pelvic pain.

Microbiology: 

A number of organisms are associated with development of PID. Often these are found within the cervix and vagina without any pathological consequences. Usually there will be some trigger that precipitates the pathological process such as sexual intercourse and uterine instrumentation.

The commonest organisms are:

1. Chlamydia Trachomatis 
2. Neisseria Gonorrhoea 
3. Mycoplasma Hominis
4. Bacteroides species
5. Actinomyces
6. Gardnerella Vaginalis
7. Ureaplasma Urealyticum
8. In 20-25% no specific cause is identified.  

  Factors Influencing upper genital tract infection (introduction of organisms to the upper genital tract).

• • Multiple sexual partners.
  • Laparoscopy and dye, hysteroscopy,
  • termination of pregnancy
  •  coitus,
  • insertion of IUCD. 
  • Menstruation is a more common time for ascending infection.

It is therefore prudent to consider screening for Chlamydia or offering universal prophylaxis for certain procedures mentioned above. Combined pill is protective.

Clinical Features of Early infection

1. Endometritis
   • Irregular and/or heavy vaginal bleeding
2. Tubal infection
   • Tubal infection and inflammation
   • Oedema and exudate formation
   • Exudate drains from distal tube and infects pelvis
   • Tubal damage/occlusion leading to mass.
3. Fitz-Hugh Curtis syndrome
   • Perihepatitis
   • Hypochondrial pain and tenderness.

 Clinical Presentation

Patients with acute PID present with a wide range of symptoms and signs that depend on their initial infecting organism.

1. Mild PID- Can be treated as outpatients.
   • • lower abdominal pain
     • vaginal discharge
     • General malaise
     • frequency and dysuria.
     • mild pyrexia
     • Mild tenderness in the lower abdomen
     • tenderness in the fornices
2. Severe PID- Usually needs admission.
   • Pain is more marked
   • Sweating, nausea or vomiting
   • Menstrual irregularity
   • Ill looking and pyrexial >38⁰C
   • Marked abdominal tenderness which may be lower abdomen or generalised with guarding or rebound
   • Vaginal examination will reveal muco-purulent discharge with exacerbation of pelvic pain with moving the cervix digitally (Cervical Excitation Tenderness= CET). Severe cases may be in septic shock.
   • A mass may be felt if abscess forms.

Investigations

• • Definitive diagnosis with microbiological confirmation may significantly delay treatment; therefore empirical treatment must be started promptly with appropriate groups of antibiotics.
  • Swabs from the vagina, cervix and urethra
  • FBC, ESR, CRP
  • Blood culture where indicated.
  • USS may show hydrosalpinges and tubo-ovarian abscesses.
  • If partners are not traced and treated, re-infection may occur.

Chronic Pelvic Inflammatory Disease

• • This is an important cause of persistent pelvic pain, with dyspareunia and dysmenorrhoea. 
  • The course is marked by acute and subacute relapses. 
  • It usually follows an acute infection, treatment of which was delayed or inadequate.
  • Secondary infertility may be the only complaint.

Treatment:

• • The antibiotic of choice should be broad enough to cover and treat common causes of PID.
  • The regime should therefore cover Chlamydia, anaerobes and Neisseria gonorrhoea.
  • The route of administration depends on the severity of the illness with unwell patients requiring admission. 

Mild PID: 

• • Oral antibiotics are usually adequate
  • Doxycyline 100mg bd daily for 5-7 days 
  • Metronidazole 400mg tds for 5-7 days.
  • Ciprofloxacin 500mg bd can be used as second-line treatment in place of the above two drugs. 

In cases where an IUCD is in-situ, there is evidence to show that removal improves outcome, though this should be considered if not better after 24-48 hours of antibiotic treatment. Arrangements should be made to reassess with 7 days.

Severe PID: 

• • These patients should be admitted to hospital. 
  • Intravenous antibiotic therapy should be commenced with the following:
  • Ampicillin500mg ivi 8 hourly
  • Gentamicin 80mg tds or Chloramphenicol 500mg 6 hourly
  • Metronidazole 500mg tds (can be given rectally).
  • If there is satisfactory improvement within 72 hours, oral antibiotics (metronidazole 400g bd Doxycycline 100mg BD) can given for 7 days.

If there is no improvement after 24-48 hours of IV antibiotics or if there is clinical suggestions of a pelvic mass, laparotomy is indicated

This is infection of the genital tract occurring at any time after delivery up to 42 days postpartum. It is a major cause of direct maternal death.

Predisposing factors include:

• Prolonged labour (repeated vaginal examinations)
• Prolonged rupture of membranes
• Operative delivery
• Retained products of conception
• Immunosuppressive disease

Signs and symptoms

Diagnosis is based on clinical findings:

Endometritis

• Fever,
• chills
• Lower abdominal pain
• Offensive lochia,
• may be purulent
• Uterine tenderness

Pelvic abscess

• Spiking fever and chills
• Lower abdominal pain and distension
• Bowel symptoms (eg diarrhoea)
• Lower abdominal tenderness, guarding, Tender uterus

Peritonitis

• Low-grade fever/chills
• Lower abdominal pain
• Moderate to severe abdominal tenderness 
• Guarding
• Reduced/absent bowel sounds

Management of puerperal sepsis

Aggressive treatment is important. The patient should be admitted for investigations, intravenous therapy, and surgical management if indicated.

Investigations

• These should be aimed at identifying the most likely source or focus of infection, causative organism(s), antibiotic sensitivities, as well as assessing severity of the illness.

Investigations include:

• FBC (general assessment and pre-operative assessment)
• U&Es (in seriously-ill patients at risk of renal compromise and pre-operative assessment)
• Blood cultures
• Swabs from cervix and lochia (for Microscopy Culture Sensitivity)
• Pelvic ultrasonography may be helpful (not mandatory)

Management

1. Supportive management includes:
   • Analgesia, antipyretics
   • Intravenous fluids (Ringer’s lactate or Normal saline)
   • Monitoring of vital signs and renal function
   • Nasogastric tube (in cases of peritonitis)
2. Antibiotic therapy

The patient should be commenced on broad spectrum, triple intravenous antibiotic therapy. Puerperal infection is commonly poly-microbial. Therapy is initially directed at most of the mixed flora that typically cause puerperal infections.

• • Ampicillin 1-2g IV qid, Metronidazole 500mg IV tds and Gentamicin 3-5mg/kg IV daily 
  • Rocephin 1g-2g IV bd may be used if Ampicillin is not available. 
  • Another alternative is Benzylpenicillin 5MU IV qid
  • Metronidazole may be given rectally at a dose of 1g 12hourly.
  • Gentamicin should be used with caution at reduced doses or avoided where there is renal compromise. Check U&E before prescribing Gentamicin. 
  • Consider Chloramphenicol 50mg/kg in 4 divided doses if Gentamicin contraindicated.

2. • Therapy may be reviewed on receiving culture and sensitivity results. Poor response to antibiotics may indicate immunosuppression, antibiotic resistance and/or a pelvic/abdominal pus collection.
3. Surgical management
   • • In case of a pelvic abscess, the patient should be prepared for laparotomy and drainage of the abscess.
     • Retained placental tissue should be evacuated carefully with ovum forceps or a large, blunt curette. Care must be taken because there is a high risk of uterine perforation post-partum and in the presence of infection. 

Antibiotics should be commenced at least 12hr before the procedure if possible

There are dedicated rape clinics at main teaching hospitals, where comprehensive services are offered for free. In Harare, the Adult Rape Clinic is situated at Mbuya Nehanda Maternity Hospital (Parirenyatwa).The Family Support Trust Clinic, which provides services for survivors aged 16 years and under, is situated at Harare Central Hospital. 

In Bulawayo, both Mpilo Central and United Bulawayo Hospitals offer similar services at dedicated clinics. Outside normal working hours, survivors can be seen in Casualty Departments.

Survivors need to be attended to as soon as possible. If there are specific problems that the Registrar, Government Medical Officer and Sexual Assault Nurse Practitioner are unable to deal with, the case should be referred to a Consultant. Refer paediatric survivors to Paediatric Teams or see national guidelines on Management of Sexual Violence.

Principles of management 

• History-taking
• Prompt  management of acute medical needs 
• Forensic medical examination & completion of the medical affidavit form
• Collection of evidence (e g clothing, forensic specimens)
• HIV pre-test and post-test counselling, testing and post-exposure prophylaxis
• Pregnancy testing and administration of emergency contraception
• Prophylactic antibiotics for sexually transmitted diseases
• Referral for counselling and psychological support

If a survivor is seen out of normal working hours and a senior is not immediately available to attend to her, the Seniour Resident Medical Officer can start to address time-sensitive issues such as HIV post-exposure prophylaxis and emergency contraception. Prophylactic antibiotics for sexually transmitted diseases, as well as any acute medical needs are also addressed at this point.

 HIV Post-Exposure Prophylaxis (PEP) 

Survivors should be offered pre-counselling and rapid testing for HIV infection. Those who present within 72 hours and test HIV-negative should be offered PEP as soon as possible.

Recommended PEP Regimen for Adults and Children >40kg

Combivir (AZT 300mg+Lamivudine150mg) 1tablet twice daily  and Kaletra (Lopinavir          200mg +Ritonavir 50mg) 2 capsules twice daily x 28 days

NB: If Kaletra is not available, use combivir + efavirenz only

Emergency contraception

Emergency contraception should be offered to all female survivors who present within 5 days (except girls under 10 years of age and post-menopausal women)

Oral emergency contraception is most effective if given within 72 hours. It may be given between 72 and 120 hours with some effect.

• The copper intrauterine contraceptive device is effective if inserted up to 120 hours after the incident. Appropriate antibiotic prophylaxis is required. It is more effective than oral emergency contraception between 72 and 120 hours. The device can be removed after the next period or it may be retained for continuing contraception if desired.
• After emergency contraception has been used, pregnancy testing should be offered if the next expected period is late, shorter and/or lighter than usual or the survivor presents with symptoms of pregnancy.

Pregnancy Resulting From Rape

• Refer to senior registrar or consultant for  discussion of options and further management.

Prophylaxis for Sexually Transmitted Infections

• Even if there is no evidence of STI, give prophylactic antibiotics to survivors who present at 0-7 days following sexual assault.
• Those who present asymptomatically after 7 days should receive the same antibiotics.

OPTIONS

1. Ciprofloxacin 500mg stat or Cefixime 400mg  orally stat
2. Ceftriaxone 125mg IM stat or Spectinomycin 1g IM stat then doxycline 100mg po tds x 1week
3. pregnant or breastfeeding:

   Cefixime            400m

4. Presumptive Treatment of Sexually Transmitted Infections

 Survivors who present late (eg several weeks or  months after the sexual assault) may have symptoms. If possible, a diagnosis should be made and appropriate treatment given. Where testing is not possible, presumptive treatment should be offered. Patients with genital discharge should be given antibiotics to cover Gonorrhoea, Chlamydia and Trichomoniasis.

 Follow-up 

If a survivor is seen in a sexual assault referral clinic, follow-up for continuing medical care and psychological support will be arranged at the time. If she is seen in Casualty, she should be referred to a sexual assault referral clinic as soon as possible for a follow-up management plan.

Cervical Cancer Screening

Invasive Cervical Cancer (ICC) is the most common cancer in Zimbabwean women occurring in 27 % of women diagnosed with cancer. Cervical cancer rarely occurs in women under 30 years with about 80% - 90 % as histologically confirmed squamous cell carcinoma and 10- 20% as adenocarcinomas. 

The primary cause of cervical cancer is infection with one or more high risk types of the human papillomavirus (HPV) types 16, 18, 31, 32,33, 35, 45, 56,58). If HPV persists and results in development  of precancer (CIN). If left untreated can lead to ICC in 10- 20 years for HIV negative women. Most cervical cancers can be prevented by early detection (screening) and treatment of precancerous lesions (CIN). In HIV infected women, progression of precancerous lesions to ICC is much faster, within 5- 7 years of acquisition of high risk HPV infection.

The Four Components of Cervical Cancer Control

• Primary Prevention.
• Early detection, through awareness and organized screening programmes.
• Diagnosis and treatment.
• Palliative care for advanced disease.

Primary Prevention

• Education and awareness raising to reduce high risk sexual behaviours, reduce smoking, avoid multiple partners. 
• Introduction of HPV vaccine Programmes to target girls / women before exposure to HPV infection. 

Early Detection

• Organized screening programmes, choice of screening test depends on available resources in the health system (trained health workers, laboratory services and transport).
• Screening test must be accurate, reproducible, affordable, acceptable, safe and easy to perform and easy to follow- up. These include: 
  • Cytology: conventional (Pap smear) and liquid based.
  • Visual inspection : with acetic acid and cervicogram (VIAC) or Lugol’s iodine or HPV DNA test

Cytology

A sample of cells is taken from the transformation zone (TZ) of the cervix with extended tip of wooden spatula or cytobrush, sample is smeared onto a glass slide and immediately fixed with an alcohol-based solution to preserve the cells. The slide is sent to cytology laboratory where it is stained and examined using a microscope to determine whether the cells are normal or abnormal. A satisfactory smear requires adequate number of well-preserved squamous epithelial cells and adequate endocervical cells. Sensitivity of conventional cytology can be 84% and specificity over 90%.

Visual Inspection with Acetic Acid (VIA) or (Visual Inspection with Lugose Iodine)VILI

Dilute acetic acid (3-5%) is applied to the cervix and after 2 minutes, abnormal cervical epithelium turns temporarily white (aceto-white) and this is test-positive (abnormal) or negative (normal) result if no aceto-white lesion is observed. If iodine is applied to cervix precancerous lesions appear well – defined, thick, saffron- yellow in colour, while normal squamous epithelium stains brown or black and columnar retains its normal pink colour. VIA/VILI do not rely on laboratory services, immediate treatment for test positive  cases can be treated with cryotherapy or loop electro- surgical excision  procedure (LEEP). VIA has sensitivity of about 77% (range 36- 94%) specificity of 86% (range 74- 94%).

HPV DNA test

A sample of cells is collected from the cervix or vagina using swab or small brush and placed in small container with preservative solution. Specimen is transported to laboratory that performs HPV DNA testing by PCR to detect high risk HPV.

HPV infection is very common among women <30 years. HPV DNA test, can be used together with cytology or VIA\ VILI because of its high sensitivity and low specificity.

Diagnosis and Treatment of Precancer Lessions

• The standard method of diagnosis of cervical precancerous lesions is histopathological examination of tissue obtained through biopsy guided by colposcopy.
• “Screen and Treat” involves identification of test positive lesions by VIA or VILI   and immediate treatment with cryotherapy or LEEP as outpatient procedures.
• Invasive treatments such as cold knife conization which require anaesthesia and hospitalization have more complications and less preferred than cryotherapy and LEEP. Cold knife conization is appropriate when eligibility for cryotherapy and LEEP are not met.
• Hysterectomy should not be used to treat precancer, unless there are other compelling reasons to remove the uterus.
• It is essential to treat CIN2\3, the precursors for ICC.
• CIN1 lesions are more likely to resolve spontaneously.

Management of Invasive Cervical Cancer

• Needs histological confirmation from biopsy specimen.
• FIGO staging to determine extent of spread and treatment modality.
• ICC must be treated by specialists with experience at central – level facilities.
• Surgical treatment is extended hysterectomy and bilateral pelvic lymphadenectomy.
• Radiation therapy (brachy therapy and teletherapy) with or without chemotherapy is also effective treatment for ICC.

Palliative Care

Women with advanced cervical cancer should be offered palliative care.

The goal of palliative care is to offer supportive care, symptom control, end –of- life care, and bereavement care to women with advanced ICC and her family.

WHO’s analgesic ladder starts by first step to give a non- opiod, typically paracetamol, if it does not relieve the pain then opiods (eg. Codeine) and the third step morphine for severe pain.