5. Clinical flow charts for the major obstetric complications are presented at the end of each complication, where appropriate. The flowcharts illustrate the sequence of steps involved in diagnosing and managing complications and are designed to assist providers in taking quick actions to manage the complication or to stabilize and refer the case as appropriate. In the ETATMBA project we have been through all details of this document. We also traced relevant published and unpublished studies on all complications. We then made proposals to update each norm according to available evidence with adaptation to known resource constraints. In parallel with the ETATMBA project efforts to develop and update the Emergency Obstetric Care Job Aid MoHSW has noted that several other stakeholders working in maternal health have similar ambitions. All inputs to improve the “Job Aid” have gradually been provided to the “Safe Motherhood Working Group” (SMWG), led by the National Coordinator of Safe Motherhood in the MoHSW, Dr K Winani. The SMWG is currently compiling all these stakeholders’ inputs in order to authorise an official, new version of the Emergency Obstetric Care Job Aid to be available in 2014.
Administer frusemide 80 mg intravenous stat 30 minutes before the transfusion Give oxygen Investigate and treat the underlying cause of anaemia Give ferrous sulphate 200 mg every 8 hours, PLUS folic acid 5 mg once a day for three months) If in established labour: Nurse patient in a propped-up position Obtain blood for Hb, grouping and cross-matching Insert urethral catheter Administer IV frusemide 80 mg stat Give oxygen Deliver the patient Do not allow patient to bear down with contractions Assist second stage of labour by performing vacuum extraction Do active management of third stage of labour: Give uterotonic medicine within one minute of birth. Oxytocin 10 IU IM or Misoprostol 600 microgram (DO NOT ADMINISTER ERGOMETRINE) Apply controlled cord traction while applying counter traction on the uterus. Perform uterine massage; immediate massage following delivery of placenta and palpation of uterus every 15 minutes for 2 hours Monitor vital signs every half an hour post-delivery until patient is stable Monitor input of given volume of IV fluids and urinary output per hour Monitor closely for signs of heart failure post-partum until condition is stable Investigate and treat the underlying cause of anaemia Give ferrous sulphate 200 mg every 8 hours, PLUS folic acid 5 mg once a day for three months Do not give blood transfusion while in labour Transfuse packed cells 24 hours post delivery Transfuse slowly, one unit to run for 4 hours MALARIA IN PREGNANCY MANAGEMENT OF MALARIA IN PREGNANCY DISPENSARY & HEALTH CENTRE Uncomplicated malaria Investigations Take a blood smear to test for malaria parasites Take a blood for Hb level Treatment Give quinine tablets 10 mg/kg body weight by mouth every 8 hours for 7 days Give paracetamol 1 g by mouth every 8 hours for 3 days If parasitaemia and/or clinical signs persist after 3 days of treatment with quinine and if the pregnancy is not in the first trimester:
REPRODUCTIVE HEALTH UNIT OBSTETRIC MANAGEMENT PROTOCOLS DISTRICT/CENTRAL HOSPITAL PRE-ECLAMPSIA AND ECLAMPSIA PRE-ECLAMPSIA ECLAMPSIA MAGNESIUM SULPHATE PREVIOUS CAESEREAN SECTION Definition: Preeclampsia is a complication of pregnancy characterized by elevated blood pressure plus proteinuria or oedema or both. Hypertension is diagnosed when blood pressure is (BP) 140/90 mmHg or higher, on two occasions at least four hours apart or elevated systolic BP >30 mmHg, or diastolic BP >15 mmHg from levels recorded in early pregnancy. Mild hypertension is 140-150mm Hg. Diagnosis The following symptoms and signs are typically present: Convulsions Diastolic BP 90 mm Hg or more after 20 weeks gestation Differential diagnoses: Epilepsy, cerebral malaria, meningitis, encephalitis, hypoglycaemia. General management Admit in a quiet room of the hospital Place the woman on her side to reduce risk of aspiration. Keep airway clear. Protect the woman from injury. Put IV line of normal saline or Ringer's lactate Insert urinary catheter. Control convulsions Give magnesium sulphate according to protocol to control convulsions. If convulsions recur before maintenance dose of magnesium sulphate is due Loading dose 4 g of 20% solution in 200 ml of normal saline over 10 minutes plus 5 g of 50% solution in each buttock deep IM Maintenance dose 5 g of 50% solution every 4 hours till delivery or after the last convulsion which ever was the last. Monitor the patient closely. Before repeat administration, ensure that: Respiratory rate is at least 16 per minute Patellar reflex present Urinary output is Admit at hospital at 37 weeks (if coming from far) Make an assessment: find out why the caesarean section was done check the presentation and size of the baby take blood samples for haemoglobin, blood group and Deliver by caesarean section if: more than one previous caesarean section or a classical scar by elective C/S at 38 weeks malpresentation (if persisting to term) history of previous
Quinine in 10% glucose infusion or 5% glucose in normal saline; if for some reason Quinine cannot be given by infusion: Give 10mg/kg dosage by IM injection and refer immediately. Make sure you give 10% glucose concentration or one bottle of 5% glucose before administration of Quinine; be careful not to induce pulmonary oedema. Random blood sugar should be done before and after Quinine administration Shift to oral quinine (during 1st trimester) and LA (in 2nd and 3rd trimester) as soon as the patient can take orally Give paracetamol 1 g by mouth every 8 hours for 3 days Insert urethral catheter for continuous drainage and record input/output Monitor vital signs (blood pressure, pulse rate, respiratory rate) every 15 minutes REFER to hospital with an escort of a nurse and with potential blood donors if the mother has severe pallor. Continue iron and folic acid by mouth for 3 months postpartum Provide dietary advice: encourage dark green vegetable leaves, citrus fruits, liver FP advice and supplies until in better physical health (avoid IUD)
REPRODUCTIVE HEALTH UNITOBSTETRIC MANAGEMENT PROTOCOLS HOSPITAL/ CENTRAL HOSPITAL MALARIA MALARIA IN PREGNANCY ANAEMIA IN PREGNANCY PREVENTION & MANAGEMENT OF INFECTION ASSOCIATED WITH CAESAREAN SECTION Clinical Features of malaria in pregnancy As in non-pregnant adults, malaria in pregnancy may manifest as uncomplicated (severe) disease. The clinical manifestations of malaria in pregnancy are similar to those in adults (fever, feeling cold, shivering, headache, loss of appetite, body malaise, abdominal pains, joint pain, nausea, vomiting, diarrhoea However, pregnant women are at particular risk of hypoglycaemia (especially as a consequence of treatment with quinine), anaemia, and immediately after delivery (3rd stage of labour), pulmonary oedema. Intermittent Presumptive Treatment of malaria in pregnancy Intermittent Presumptive Treatment (IPT) of malaria in pregnancy is one of the major malaria preventive strategies in Malawi. At least two doses of SP, 3tablets for each dose, are given after the first trimester, at least four weeks apart, under direct observation by health personnel. Although IPT reduces the risk of malaria in pregnancy, breakthrough clinical malaria episodes can occur in patients on IPT, as well as in those receiving partial or no IPT. Management of malaria in pregnancy Treatment of uncomplicated malaria in pregnancy Uncomplicated malaria Definition of mild – moderate ANAEMIA: Hb between 7 and 11g/dl or PCV between 20 and 30% Management Treat malaria and give intermittent presumptive treatment according to protocol Give albendazole 400 mg by mouth once after 16 weeks gestation Treat proven schistosomiasis with praziquantel after 16 weeks gestation Give iron (200mg po tds) and folic acid (5mg) daily by mouth Provide dietary Encourage the woman to have a warm bath Avoid shaving in labour ward Practice universal infection prevention techniques Do proper vaginal examination – 6 swab technique Provide a clean mackintosh PROPHYLACTIC ANTIBIOTICS Give a single dose of chloramphenicol 1 g IV OR Ampicillin 2 g IV OR Cefuroxime 1 g IV to the mother after the cord is clamped and cut. THERAPEUTIC ANTIBIOTICS 8 2 6 240 48 5 1 6 48 MU
ANTEPARTUM HAEMORRHAGE (APH) PRIMARY POST PARTUM HAEMORRHAGE: SECONDARY PPH POSTABORTION Definition Vaginal bleeding from 28 weeks of pregnancy to before delivery DIFFERENTIAL DIAGNOSIS of major obstetric causes of APH Definition Increased vaginal bleeding (500 ml or greater and or causing worsening of pulse rate and blood pressure) within the first 24 hours after childbirth Management Placenta in: Call for help Inform the mother that urgent measures to stop the bleeding are needed. Lay flat, keep warm Continuous fundal massage until uterus hard Give or repeat oxytocin 10 U IM Ask the assistant to insert a urethral catheter for continuous drainage. Put up IV line with large bore and take blood for Hb, Grouping and cross matching, put up normal saline or Ringer's lactate and run it fast If peripheral veins are collapsed and hard to find, perform a saphenous cut-down immediately anterior to the medial ankle. Ask the assistant to record vital signs every 15 minutes. If vital signs deteriorate, urgently refer patient to hospital with an escorting nurse and potential blood donors. If placenta retained, repeat Definition Increased vaginal bleeding occurring between the first 24 hours after childbirth and six weeks postpartum. Symptoms Genital bleeding or increase in red lochia Fever Signs Offensive vaginal bleeding or discharge from the cervical os Variable degrees of shock Pallor Sub-involuted tender uterus. Management Give oxytocin 10 IUnits IM Rub up a contraction Empty bladder Set up IV line , Check Hb and X-match 2 units of blood and put up with saline or Ringer's lactate run L fast in the first 2 hours if patient is in shock. Put 40 units of Definition Vaginal bleeding before 28 weeks of pregnancy due to an abortion Management Rub up uterine contraction (in case of late abortion) Give oxytocic drug Empty the bladder Put up an IV drip with saline and run it fast Do VE and remove products of conception from vaginal canal Check vital signs If SEPTIC, give 1g IV stat Counsel and refer to hospital with donors
Controlled Cord Traction (CCT) If CCT failed, remove placenta manually. If not possible refer to hospital Placenta out: Rub up a contraction Give or repeat oxytocin 10 IU IM Expel the clots Empty bladder and maintain indwelling catheter Inspect the vagina with broad specula using a headlamp to identify any visible mucosal lacerations or to verify source of bleeding from the uterine cavity. Repair tears of vulva, vagina, perineum, cervix or uterus where present. Check pulse and blood pressure If uterine atony persists in spite of the above: Put 40 units of oxytocin in 1L of normal saline or Ringer's lactate & run at 60 drops per minute initially, then 40 drops per minute with a maximum of 3L. If bleeding due to uterine atony persists, do bimanual compression. If there is no improvement, refer to hospital with donors and inform the most senior person available. oxytocin in 1L of IV fluid, if necessary Give Metronidazole 500mg IV, Benzylpenicillin 2 MU IV and Gentamycin 240 mg IM Refer to hospital with donors Check haemoglobin. If cervix is open: explore uterus by gloved fingers to remove clots, placental fragments and membranes. Observe for 24 hours. Give ferrous sulphate 200 mg every 8 hours, plus folic acid 5mg once a day for 6 weeks Refer urgently with escort of a nurse and potential blood donors if: cervix is closed or if bleeding does not stop Non-obstetric causes: Cervical causes such as cancer or a benign polyp Over 50% of cases of APH remain unexplained!