Essential obstetric [614104]

Essential obstetric
and newborn care
Practical guide for mi dwives, doctors with obstetri cs
training and health care pe rsonnel who deal wi th
obstetric emergencies
2015 edition

Author
Anne-Sophie Coutin
Editorial committee
Catrin Schulte-Hillen, Bertrand Draguez, Myriam Henkens, Judith Herrera
Technical editor
Véronique Grouzard
Contributors
Margaret Bell, Marie-Claude Bottineau, Séverine Caluwaerts, Isabelle Capochichi, Eva De Plecker,Maria Pilar Luna Ramirez, Olivia Hill, Michiel Lekkerkerker, Daphné Lagrou, Nicolas Peyraud,Debbie Price, Jean Rigal, Raquel Rosenberg, Nelly Staderini
We would like to thank Martin De Smet, Frédérique Drogoul, Pauline Lechevalier, Daniel Martinez,
Richard Murphy, Maura Pedrini, Roberta Petrucci, Carlos Pilasi Menichetti, Anne Pittet,
Harriet Roggeveen, El isabeth Szumi lin and Isabel Zuniga for their contri butions to this gui de.
Published by
Médecins Sans Fronti ères
Design and layoutEvelyne Lai ssu
IllustrationsGermain Péronne
Translation
Nina Friedman
© Médecins Sans Fronti ères, 2015
All rights reserved for all countries. No reproduction, translation and adaptation may be
done without the prior permi ssion of the Copyright owner.
Médecins Sans Frontières. Essential obstetric and newborn care. 2015 Edition.
ISBN Number: 2-906498-98-X

Introduction
According to the World Health Organization, an estimate d 800 women die each day from
preventable pregnancy- and delivery-related causes. Ninety-nine percent of maternal
deaths occur in developing countries. There are a numbe r of factors limiting access to the
high quality care that would reduce this mortality to a more acceptable level; these include
limited family resources, living far from a health care facility, and the lack of a reliable
system of transportati on.
Essential obstetric and newborn care is designed as a tool to help prote ct mothers and their
children in adverse environments. It is intended for midwives, doctors with obstetrics
training, and health care pe rsonnel who de al with obstetric e mergencies.
This guide is not intended as a treatise on obstetrics, or as a replacement for years of
specialised training and experience. The goal here is to describe the essentials needed to
manage the most common illnesse s and problems encounte red during pregnancy, in order
to save the life of the mother, protect her from the sequelae of a difficult pregnancy or
delivery, and deliver the infant in the best possi ble conditions.
Not all the procedures described in this guide are within reach of all medical staff. For
example, while many obstetrical procedures fall within a midwife’ s scope of practice , she is
not qualified to perform a caesarean – though she usually helps determine that one is
indicate d. On the othe r hand, a nurse may be permitted to perform antenatal consultations,
with appropriate training. The medical demography of low-income countrie s often requires
the decentralisation of competencies. Similarly, it is important to take the paucity of
obstetricians in developing countries into account, and recognise that in some countries,
general practitioners in remote areas are trained to do difficult and caesarean deliveries.
Hence this guide aims to serve all of these variously-qualified personnel, by describing basic
technical procedure s and general manage ment of obstetric emergencies. It can also be used
as a reference tool for trai ning.
While some of the methods in this guide, such as symphysiotomy and embryotomy, may
appe ar obsolete, they have purposely been included for situations in which there is limited
or no access to caesarean secti ons.
Broadly speaking, there are two types of medical facilities that provide care for mothers and
newborns: BEmONCs, which dispense Basic Emergency Obstetric and Newborn Care, and
CEmONCs, which offer Comprehensive Emergency Obstetric and Newborn Care. The
geographic distribution of these facilities permits proximity to care, in the case of the
BEmONCs, with the CEmON Cs serving as reference facilities for more complicated deliveries.
The different procedures and techniques described in this guide are to be performed in the
relevant medi cal facility.
3

Despite all efforts, it is possible that certain errors may have been overlooked in this
manual. Please inform the authors of any errors detected. It is important to remember, that
if in doubt, it is the responsibility of the prescribing medical professional to ensure that the
dose s indicate d in this manual conform to the manufacturer’s spe cifications.
The authors would be gratefu l for any comments or criticisms to ensu re that this manual
continues to evolve and re mains adapted to the re ality of the fi eld.
Comments should be addressed to:
Médecins Sans Frontières – Gui delines
8, rue Saint Sabin – 75011 Pari s
Tel.: +33(0)1.40.21.29.29
Fax: +33(0)1.48.06.68.68
e.mail: guide.obstetrics@msf.org
This manual is also available on the internet at www.msf.org. As protocols are constantly
changing, medical staff are encouraged to check this website for updates of this e dition.
4

Table of contents
Abbreviations and acronyms …………………………………………………………………………………….13
Chapter 1: Diagnosing and monitoring pregnancy
1.1 Diagnosing pregnancy ……….. ………………………………………………………………………………17
1.1.1 Signs and symptoms of pregnancy ……………………………………………………………………..17
1.1.2 History and clinical examination ………………………………………………………………………..17
1.1.3 Other investigations …………………………………………………………………………………………17
1.2 Antenatal consultations ……………………………………………………………………………………..19
1.2.1 Aims of antenatal monitoring ……………………………………………………………………………19
1.2.2 Timing of antenatal consultations ………………………………………………………………………19
1.2.3 First consultation ……………………………………………………………………………………………..19
1.2.4 Subsequent consultations ………………………………………………………………………………….22
1.2.5 Preventive treatments ………………………………………………………………………………………23
1.2.6 Preparation for the birth …………………………………………………………………………………..26
1.3 Monitoring complicated pregnancies …………………………………………………………………..27
1.3.1 Situations requiring higher level monitoring ………………………………………………………..27
1.3.2 Situations requiring special precautions for delivery ……………………………………………..27
1.3.3 Situations requiring higher level monitoring during pregnancy AND special
precautions for delivery ……………………………………………………………………………………………28
Chapter 2: Bleeding during the first half of pregnancy2.1 Abortion ………..
………………………………………………………………………………………………….33
2.1.1 Diagnosis ………………………………………………………………………………………………………..33
2.1.2 Differential diagnosis ………………………………………………………………………………………..33
2.1.3 Management …………………………………………………………………………………………………..33
2.2 Ectopic pregnancy ………………………………………………………………………………………………36
2.2.1 Diagnosis ………………………………………………………………………………………………………..36
2.2.2 Differential diagnosis ………………………………………………………………………………………..37
2.2.3 Management …………………………………………………………………………………………………..37
2.3 Molar pregnancy (hydatidiform mole) ………………………………………………………………….38
2.3.1 Diagnosis ………………………………………………………………………………………………………..38
2.3.2 Management …………………………………………………………………………………………………..38
2.3.3 Follow-up ………………………………………………………………………………………………………..39
2.4 Cervicitis ……………………………………………………………………………………………………………40
2.4.1 Diagnosis ………………………………………………………………………………………………………..40
2.4.2 Management …………………………………………………………………………………………………..40
2.5 Functional bleeding ……………………………………………………………………………………………41
2.5.1 Diagnosis ………………………………………………………………………………………………………..41
2.5.2 Management …………………………………………………………………………………………………..41
Chapter 3: Bleeding during the second half of pregnancy3.1 Placenta praevia ………..
………………………………………………………………………………………45
3.1.1 Different types of placenta praevia …………………………………………………………………….45
3.1.2 Diagnosis ………………………………………………………………………………………………………..45
3.1.3 Management …………………………………………………………………………………………………..46
5

3.2 Abruptio placentae …………………………………………………………………………………………….48
3.2.1 Diagnosis ………………………………………………………………………………………………………..48
3.2.2 Management …………………………………………………………………………………………………..48
3.3 Uterine rupture ………………………………………………………………………………………………….50
3.3.1 Circumstances in which uterine rupture occurs …………………………………………………….50
3.3.2 Diagnosis ………………………………………………………………………………………………………..50
3.3.3 Management …………………………………………………………………………………………………..52
3.4 Diagnosis of bleeding during the second half of pregnancy (summary) ……………………54
Chapter 4: Pathologies during pregnancy and pregnancy-related disorders
4.1 Iron deficiency anaemia ……….. ……………………………………………………………………………59
4.1.1 Diagnosis ………………………………………………………………………………………………………..59
4.1.2 Treatment ……………………………………………………………………………………………………….59
4.2 Bacterial infections …………………………………………………………………………………………….60
4.2.1 Meningitis ……………………………………………………………………………………………………….60
4.2.2 Typhoid fever …………………………………………………………………………………………………..60
4.2.3 Shigellosis ……………………………………………………………………………………………………….60
4.2.4 Syphilis ……………………………………………………………………………………………………………61
4.2.5 Gonorrhoea …………………………………………………………………………………………………….61
4.2.6 Cystitis and asymptomatic bacteriuria ………………………………………………………………..61
4.2.7 Pyelonephritis ………………………………………………………………………………………………….62
4.3 Parasitic infections ……………………………………………………………………………………………..63
4.3.1 Malaria …………………………………………………………………………………………………………..63
4.3.2 Amoebiasis ……………………………………………………………………………………………………..65
4.3.3 Ascariasis and ancylostomiasis (hookworms) ………………………………………………………65
4.4 Viral infections …………………………………………………………………………………………………..66
4.4.1 Genital herpes …………………………………………………………………………………………………66
4.4.2 Varicella (chickenpox) ……………………………………………………………………………………….66
4.4.3 Hepatitis …………………………………………………………………………………………………………66
4.4.4 HIV infection ……………………………………………………………………………………………………67
4.5 Pregnancy induced-hypertension and pre-eclampsia …………………………………………….68
4.5.1 Diagnosis of pre-eclampsia ………………………………………………………………………………..68
4.5.2 Diagnosis of severe pre-eclampsia ……………………………………………………………………..68
4.5.3 Management of isolated hypertension ……………………………………………………………….69
4.5.4 Management of mild pre-eclampsia …………………………………………………………………..69
4.5.5 Management of severe pre-eclampsia ………………………………………………………………..70
4.5.6 Secondary prophylaxis for severe pre-eclampsia …………………………………………………..72
4.6 Eclampsia ………………………………………………………………………………………………………….73
4.6.1 Diagnosis ………………………………………………………………………………………………………..73
4.6.2 Management …………………………………………………………………………………………………..73
4.6.3 Secondary prophylaxis ………………………………………………………………………………………73
4.7 Abnormally large uterus ……………………………………………………………………………………..74
4.7.1 Diagnosis ………………………………………………………………………………………………………..74
4.7.2 Management …………………………………………………………………………………………………..74
4.8 Polyhydramnios …………………………………………………………………………………………………75
4.8.1 Acute polyhydramnios ………………………………………………………………………………………75
4.8.2 Chronic polyhydramnios ……………………………………………………………………………………75
6

4.9 Premature rupture of membranes ……………………………………………………………………….76
4.9.1 Diagnosis ………………………………………………………………………………………………………..76
4.9.2 Risks ……………………………………………………………………………………………………………….76
4.9.3 Management …………………………………………………………………………………………………..76
4.10 Threatened preterm delivery …………………………………………………………………………….78
4.10.1 Causative factors ……………………………………………………………………………………………78
4.10.2 Management …………………………………………………………………………………………………78
4.10.3 Preterm delivery …………………………………………………………………………………………….79
4.10.4 Preventing preterm delivery …………………………………………………………………………….79
4.11 Intrauterine foetal death …………………………………………………………………………………..80
4.11.1 Diagnosis ………………………………………………………………………………………………………80
4.11.2 Management …………………………………………………………………………………………………80
Chapter 5: Normal delivery and procedures related to vaginal delivery
5.1 Normal delivery ……….. ……………………………………………………………………………………….85
5.1.1 General recommendations ………………………………………………………………………………..85
5.1.2 Diagnosing the start of labour ……………………………………………………………………………85
5.1.3 Stages of labour ……………………………………………………………………………………………….85
5.1.4 First stage: dilation and descent of the foetus ……………………………………………………..86
5.1.5 Second stage: delivery of the foetus ……………………………………………………………………89
5.1.6 Oxytocin administration ……………………………………………………………………………………92
5.1.7 Umbilical cord clamping ……………………………………………………………………………………92
5.2 Monitoring labour and delivery …………………………………………………………………………..93
5.2.1 Partograph ……………………………………………………………………………………………………..93
5.2.2 Postpartum maternal monitoring in the delivery room ………………………………………….95
5.3 Artificial rupture of the membranes …………………………………………………………………….96
5.3.1 Indications ………………………………………………………………………………………………………96
5.3.2 Precautions ……………………………………………………………………………………………………..96
5.3.3 Contra-indications ……………………………………………………………………………………………96
5.3.4 Technique ……………………………………………………………………………………………………….96
5.4 Prolapsed cord …………………………………………………………………………………………………..98
5.4.1 Diagnosis ………………………………………………………………………………………………………..98
5.4.2 Management …………………………………………………………………………………………………..99
5.5 Nuchal cord ……………………………………………………………………………………………………..100
5.6 Instrumental delivery ……………………………………………………………………………………….101
5.6.1 Vacuum extractor …………………………………………………………………………………………..101
5.6.2 Forceps …………………………………………………………………………………………………………104
5.7 Symphysiotomy ……………………………………………………………………………………………….105
5.7.1 Indications …………………………………………………………………………………………………….105
5.7.2 Conditions ……………………………………………………………………………………………………..105
5.7.3 Contra-indications ………………………………………………………………………………………….105
5.7.4 Equipment …………………………………………………………………………………………………….106
5.7.5 Technique ……………………………………………………………………………………………………..106
5.7.6 Post-operative care ………………………………………………………………………………………..108
5.7.7 Complications ………………………………………………………………………………………………..108
5.8 Episiotomy ………………………………………………………………………………………………………109
5.8.1 Indications …………………………………………………………………………………………………….109
5.8.2 Equipment …………………………………………………………………………………………………….109
5.8.3 Technique ……………………………………………………………………………………………………..109
7

5.9 Perineal repair …………………………………………………………………………………………………111
5.9.1 Equipment …………………………………………………………………………………………………….111
5.9.2 Technique ……………………………………………………………………………………………………..112
5.9.3 Post-operative care ………………………………………………………………………………………..113
5.9.4 Management of complications …………………………………………………………………………114
5.10 Deinfibulation ………………………………………………………………………………………………..115
5.10.1 Equipment …………………………………………………………………………………………………..115
5.10.2 Technique ……………………………………………………………………………………………………115
Chapter 6: Special deliveries
6.1 Breech presentation ……….. ……………………………………………………………………………….119
6.1.1 The different breech presentations …………………………………………………………………..119
6.1.2 Diagnosis ………………………………………………………………………………………………………119
6.1.3 Management …………………………………………………………………………………………………120
6.1.4 Breech delivery problems ………………………………………………………………………………..122
6.2 Twin pregnancy ………………………………………………………………………………………………..126
6.2.1 Diagnosis ………………………………………………………………………………………………………126
6.2.2 Management during pregnancy ……………………………………………………………………….126
6.2.3 Management during delivery …………………………………………………………………………..126
6.3 Total breech extraction …………………………………………………………………………………….128
6.3.1 Relative contra-indication ……………………………………………………………………………….128
6.3.2 Technique ……………………………………………………………………………………………………..128
6.4 Caesarean section …………………………………………………………………………………………….130
6.4.1 Indications …………………………………………………………………………………………………….130
6.4.2 Prerequisites for performing a caesarean ………………………………………………………….130
6.4.3 Pre-operative care ………………………………………………………………………………………….130
6.4.4 Peri-operative care …………………………………………………………………………………………131
6.4.5 Post-operative care ………………………………………………………………………………………..131
Chapter 7: Labour dystocia and malpresentations7.1 Prolonged labour ………..
……………………………………………………………………………………137
7.1.1 Diagnosis ………………………………………………………………………………………………………137
7.1.2 Management …………………………………………………………………………………………………137
7.2 Obstructed labour …………………………………………………………………………………………….140
7.2.1 Diagnosis ………………………………………………………………………………………………………140
7.2.2 Possible causes ………………………………………………………………………………………………140
7.2.3 Complications ………………………………………………………………………………………………..140
7.2.4 Management …………………………………………………………………………………………………140
7.2.5 Prevention/management of vaginal fistulae ………………………………………………………141
7.3 Labour induction ………………………………………………………………………………………………142
7.3.1 Indications …………………………………………………………………………………………………….142
7.3.2 Methods ……………………………………………………………………………………………………….142
7.3.3 Conditions ……………………………………………………………………………………………………..143
7.4 The use of oxytocin during labour ………………………………………………………………………145
7.4.1 Indications …………………………………………………………………………………………………….145
7.4.2 Risks of using oxytocin during labour ………………………………………………………………..145
7.4.3 Contra-indications to the use of oxytocin during labour ………………………………………145
7.4.4 Situations requiring special precautions …………………………………………………………….145
7.4.5 Conditions for oxytocin use ……………………………………………………………………………..145
8

7.5 Shoulder dystocia …………………………………………………………………………………………….147
7.5.1 Management …………………………………………………………………………………………………147
7.5.2 Methods of last resort …………………………………………………………………………………….148
7.6 Transverse lie and shoulder presentation …………………………………………………………..149
7.6.1 Diagnosis ………………………………………………………………………………………………………149
7.6.2 Possible causes ………………………………………………………………………………………………150
7.6.3 Management …………………………………………………………………………………………………150
7.7 External version ……………………………………………………………………………………………….152
7.7.1 Conditions ……………………………………………………………………………………………………..152
7.7.2 Contra-indications ………………………………………………………………………………………….152
7.7.3 Technique ……………………………………………………………………………………………………..152
7.8 Internal version ………………………………………………………………………………………………..154
7.8.1 Indications and conditions ……………………………………………………………………………….154
7.8.2 Technique ……………………………………………………………………………………………………..154
7.9 Face presentation …………………………………………………………………………………………….156
7.9.1 Diagnosis ………………………………………………………………………………………………………156
7.9.2 Management …………………………………………………………………………………………………156
7.10 Brow presentation ………………………………………………………………………………………….159
7.10.1 Diagnosis …………………………………………………………………………………………………….159
7.10.2 Management ……………………………………………………………………………………………….160
Chapter 8: Third stage of labour
8.1 Normal third stage of labour ……….. ……………………………………………………………………165
8.1.1 Description …………………………………………………………………………………………………….165
8.1.2 Routine prevention of postpartum haemorrhage ……………………………………………….165
8.1.3 Monitoring …………………………………………………………………………………………………….166
8.1.4 Examination of the placenta ……………………………………………………………………………167
8.2 Early postpartum haemorrhage …………………………………………………………………………168
8.2.1 Possible causes ………………………………………………………………………………………………168
8.2.2 Management during the first 30 minutes ………………………………………………………….168
8.2.3 Cause-specific management …………………………………………………………………………….169
8.2.4 Management of persistent bleeding …………………………………………………………………170
8.3 Late postpartum haemorrhage ………………………………………………………………………….172
8.3.1 Diagnosis ………………………………………………………………………………………………………172
8.3.2 Possible causes ………………………………………………………………………………………………172
8.3.3 Management …………………………………………………………………………………………………172
8.4 Uterine inversion ……………………………………………………………………………………………..173
8.4.1 Diagnosis ………………………………………………………………………………………………………173
8.4.2 Management …………………………………………………………………………………………………173
8.5 Cervical and vaginal tears ………………………………………………………………………………….176
8.5.1 Diagnosis ………………………………………………………………………………………………………176
8.5.2 Management …………………………………………………………………………………………………176
Chapter 9: Intrauterine procedures9.1 Precautions required for intrauterine procedures ………..
……………………………………..181
9.1.1 Precautions common to all intrauterine procedures ……………………………………………181
9.1.2 Specific precautions for manual procedures ……………………………………………………….181
9

9.2 Manual removal of the placenta ………………………………………………………………………..182
9.2.1 Indications …………………………………………………………………………………………………….182
9.2.2 Technique ……………………………………………………………………………………………………..182
9.3 Uterine exploration ………………………………………………………………………………………….183
9.3.1 Indications …………………………………………………………………………………………………….183
9.3.2 Technique ……………………………………………………………………………………………………..183
9.4 Digital curettage ………………………………………………………………………………………………184
9.4.1 Indications …………………………………………………………………………………………………….184
9.4.2 Technique ……………………………………………………………………………………………………..184
9.5 Manual vacuum aspiration (MVA) ……………………………………………………………………..185
9.5.1 Indications …………………………………………………………………………………………………….185
9.5.2 Contra-indications ………………………………………………………………………………………….185
9.5.3 Equipment …………………………………………………………………………………………………….185
9.5.4 Technique ……………………………………………………………………………………………………..186
9.5.5 Patient follow-up ……………………………………………………………………………………………188
9.5.6 Complications ………………………………………………………………………………………………..188
9.6 Instrumental curettage ……………………………………………………………………………………..189
9.6.1 Indications …………………………………………………………………………………………………….189
9.6.2 Precautions ……………………………………………………………………………………………………189
9.6.3 Equipment …………………………………………………………………………………………………….189
9.6.4 Technique ……………………………………………………………………………………………………..189
9.6.5 Patient follow-up ……………………………………………………………………………………………191
9.6.6 Complications ………………………………………………………………………………………………..191
9.7 Embryotomy ……………………………………………………………………………………………………193
9.7.1 General conditions and precautions ………………………………………………………………….193
9.7.2 Contra-indications ………………………………………………………………………………………….194
9.7.3 Equipment …………………………………………………………………………………………………….194
9.7.4 Craniotomy for cephalic presentation with entrapment ………………………………………195
9.7.5 Cranioclasis ……………………………………………………………………………………………………196
9.7.6 Craniotomy for retention of the aftercoming head (breech) …………………………………196
9.7.7 Decapitation for transverse lie …………………………………………………………………………197
Chapter 10: Newborn care in the maternity hospital
10.1 Routine care and examination in the first few hours of life.. ……… ……………………….201
10.1.1 Clearing the airway ………………………………………………………………………………………201
10.1.2 Cord clamping and cord care ………………………………………………………………………….201
10.1.3 Apgar score ………………………………………………………………………………………………….201
10.1.4 Clinical examination ……………………………………………………………………………………..202
10.1.5 Thermoregulation …………………………………………………………………………………………203
10.1.6 Feeding ……………………………………………………………………………………………………….203
10.1.7 Preventive treatments …………………………………………………………………………………..203
10.1.8 Vaccinations ………………………………………………………………………………………………..204
10.1.9 Daily monitoring …………………………………………………………………………………………..204
10.2 Neonatal resuscitation ……………………………………………………………………………………205
10.2.1 Basic resuscitation ………………………………………………………………………………………..205
10.2.2 After resuscitation ………………………………………………………………………………………..207
10.3 Care of the sick newborn …………………………………………………………………………………208
10.3.1 Danger signs ………………………………………………………………………………………………..208
10.3.2 Management of life-threatening emergencies ………………………………………………….208
10

10.3.3 Management of symptomatic neonatal infections ……………………………………………209
10.3.4 Management of asymptomatic newborns at risk of neonatal infection ……………….210
10.3.5 Management of hypoglycaemia ……………………………………………………………………..211
10.3.6 Management of jaundice ………………………………………………………………………………212
10.4 Specific care when the mother has a transmissible infection ………………………………214
10.4.1 Syphilis ………………………………………………………………………………………………………..214
10.4.2 Genital gonococcal or chlamydial infection ………………………………………………………214
10.4.3 Genital herpes ……………………………………………………………………………………………..215
10.4.4 Hepatitis B infection ……………………………………………………………………………………..215
10.4.5 HIV infection ………………………………………………………………………………………………..215
10.4.6 Active pulmonary tuberculosis ……………………………………………………………………….216
10.5 Care of the low birth weight newborn (1500-2500 g) …………………………………………217
10.5.1 Kangaroo care ……………………………………………………………………………………………..217
10.5.2 Thermoregulation …………………………………………………………………………………………218
10.5.3 Feeding ……………………………………………………………………………………………………….218
10.5.4 Monitoring …………………………………………………………………………………………………..218
10.6 Criteria for discharge from the maternity hospital ……………………………………………..219
Chapter 11: Postpartum/postnatal period
11.1 Normal postpartum events ……….. ……………………………………………………………………223
11.1.1 Uterine involution …………………………………………………………………………………………223
11.1.2 Lochia …………………………………………………………………………………………………………223
11.1.3 Lactation ……………………………………………………………………………………………………..223
11.1.4 Return of menstrual periods …………………………………………………………………………..223
11.2 Postpartum care for the mother ………………………………………………………………………224
11.2.1 In the maternity hospital ……………………………………………………………………………….224
11.2.2 Upon discharge …………………………………………………………………………………………….225
11.3 Postnatal consultations …………………………………………………………………………………..226
11.3.1 Timing of postnatal consultations …………………………………………………………………..226
11.3.2 For the mother ……………………………………………………………………………………………..226
11.3.3 For the infant ……………………………………………………………………………………………….227
11.3.4 Postnatal care card ……………………………………………………………………………………….227
11.4 Postpartum complications ………………………………………………………………………………228
11.4.1 Excessive uterine bleeding ……………………………………………………………………………..228
11.4.2 Infectious complications ………………………………………………………………………………..228
11.4.3 Breast-related complications ………………………………………………………………………….229
11.4.4 Urine leakage ………………………………………………………………………………………………229
11.4.5 Psychological disorders …………………………………………………………………………………230
11.5 Contraception ………………………………………………………………………………………………..231
11.5.1 Contraceptive methods …………………………………………………………………………………231
11.5.2 For women who are breastfeeding ………………………………………………………………….232
11.5.3 For women who are not breastfeeding ……………………………………………………………232
11.5.4 Special situations ………………………………………………………………………………………….233
Chapter 12: Termination of pregnancy on request12.1 Care before abortion ………..
…………………………………………………………………………….237
12.1.1 Information and counselling …………………………………………………………………………..237
12.1.2 History and examination ……………………………………………………………………………….237
12.1.3 Choosing a method ……………………………………………………………………………………….237
11

12.2 Medical abortion ……………………………………………………………………………………………239
12.2.1 Contra-indications ………………………………………………………………………………………..239
12.2.2 Protocol ………………………………………………………………………………………………………239
12.2.3 Patient information ………………………………………………………………………………………240
12.2.4 Post-abortion visit ………………………………………………………………………………………..240
12.3 Surgical abortion …………………………………………………………………………………………….242
12.3.1 Relative contra-indications …………………………………………………………………………….242
12.3.2 Equipment …………………………………………………………………………………………………..242
12.3.3 Technique ……………………………………………………………………………………………………242
12.3.4 Patient follow-up ………………………………………………………………………………………….243
12.3.5 Complications ………………………………………………………………………………………………243
Appendices
1. Antenatal care card …. …………………………………………………………………………………………247
2. Bakri intrauterine balloon …………………………………………………………………………………….249
3. Breastfeeding …………………………………………………………………………………………………….251
4. Daily amounts required for feeding ……………………………………………………………………….256
5. Placing an oro/nasogastric tube ……………………………………………………………………………258
6. Postnatal care card ……………………………………………………………………………………………..259
Index……………………………………………………………………………………………………………………261
12

Abbreviations and acronyms
ACT artemisinin-based combi nation therapy
AL artemether/lumefantrine (coartemether)
AQ amodiaquine AS artesunateBCG bacillus Calmette-GuérinBEmONC basic emergency obstetric and newborn care BP blood pressureC° degree CelsiusCEmONC complete emergency obstetric and newborn caredl decilitreg gramHBV hepatitis B virusHIVhuman immunodeficiency virusIM intramuscular administrationIU international unitIV intravenous administrationkg kilogramLMP last menstrual periodM millionµg microgrammg milligramMgSO4 magnesium sulfate ml millilitremmHg millimetre of mercurymmol millimoleMQ mefloquineMVA manual vacuum aspiration PIH pregnancy-induced hypertensionPMTCT prevention of mother-to-child transmissionPOper os – oral administrationRF risk factor(s)SCsubcutaneous administrationSP sulfadoxine/pyrimethaminetab tabletTB tuberculosisTTtetanus toxoidUNICEF United Nations Children's FundWHO World Health Organization
13

Chapter 1:
Diagnosing and monitoring pregnancy
1.1 Diagnosing pregnancy ………………………………………………………………………………..17
1.1.1 Signs and symptoms of pregnancy ………………………………………………………..17
1.1.2 History and clinical examination …………………………………………………………..17
1.1.3 Other investigations ……………………………………………………………………………17
1.2 Antenatal consultations ……………………………………………………………………………..19
1.2.1 Aims of antenatal monitoring ………………………………………………………………19
1.2.2 Timing of antenatal consultations …………………………………………………………19
1.2.3 First consultation ………………………………………………………………………………..19
1.2.4 Subsequent consultations …………………………………………………………………….22
1.2.5 Preventive treatments …………………………………………………………………………23
1.2.6 Preparation for the birth ……………………………………………………………………..26
1.3 Monitoring complicated pregnancies …………………………………………………………..27
1.3.1 Situations requiring higher level monitoring …………………………………………..27
1.3.2 Situations requiring special precautions for delivery ……………………………….27
1.3.3 Situations requiring higher level monitoring during pregnancy
AND special precautions for delivery (CEmONC) ……………………………………………..281

1.1 Diagnosing pregnancy
1.1.1 Signs and symptoms of pregnancy
The first sign of pregnancy is amenorrheaacombined with a progressive incre ase in the size
of the uterus starting 7 to 8 weeks after the last menstrual period.
During the first trimester, breast changes (increased size, tenderness, vascularisation and
swolle n areolas), pollakiuria (freque nt need to urinate) and transitory nausea/vomiting are
common.In the second trimester the mother begins to feel foetal movement and, in some cases,
uterine contractions. Foetal heart tone can be heard.Signs and symptoms of pregnancy by gestational age are presented in the Table 1.1, on
following page.
1.1.2 History and clinical examination
See Section 1.2.
1.1.3 Other investigations
Pregnancy test
While a pregnancy test is not routinely necessary, it is always indicated for suspected
ectopic pregnancy or e arly diagnosis of a pregnancy to be termi nated.
Ultrasound
Ultrasound is not routi nely necessary.
aFor amenorrhoea (absence of menstrual periods) without other signs of pregnancy, rule out other causes:
physiological (breastfeeding), drug-related (e.g., contraceptives up to 3 months after stopping,
antipsychotics and corti costeroids), endocrine (e.g., thyroid di sorder), psychological, nutritional, etc.Diagnosing and moni toring pregnancy
171

Table 1.1 – Signs and symptoms of pregnancy by gestational age
Weeks since last menstrual period (weeks LMP)
04681 2 1 6 1 8 2 0 2 4 4 0 / 4 1
Amenorrhea
Uterine enlargementGastrointestinal disturbancesBreast changesUrinary frequencyFoetal movement (multipara)Foetal movement (primipara)Uterine contractionsFoetal movements feltHeart tone detected by
Doppler ultrasound
Heart tone heard with
Pinard stethoscope
Transabdominal ultrasoundUrine pregnancy test
period during which these signs/symptoms are variably present.period during which these signs/symptoms are present.Chapter 1
18

1.2 Antenatal consultations
1.2.1 Aims of antenatal monitoring
– Screening for and management of pathologies: hypertension, anaemia, malaria, syphilis,
urinary tract infection, HIV infection, malnutrition, vitamin and micronutrie nt deficiencies,
etc.
– Screening for and management of obstetric complications: uterine scar, abnormal
presentation, premature rupture of me mbranes, multiple pregnancy, metrorrhagi a, etc.
– Routine prevention of maternal and neonatal tetanus, anaemia, mother-to-child HIV
transmission, malaria (in ende mic areas), etc.
– Devising a birth plan; counsel ling; preparation for the bi rth.
1.2.2 Timing of antenatal consultations
Four ante natal consul tations are re comme nded for uncompl icated pregnanci es1.
If the patient does not come in until the sixth month or later, try to have at least two
consultations before the bi rth.
Table 1.2 – Schedul e of antenatal consul tations
*The gestational age is expressed in weeks since last menstrual period (LMP) or, less precisely, in weeks of
pregnancy. Pregnancy lasts 9 months or 40 or 41 weeks LMP, depending on the country.
Closer monitoring may be needed, depending on the problems detected and the patient’s
history (Section 1.3).
1.2.3 First consultation
A. Interview
– General feel ing about the pregnancy (probl ems/concerns).
– Social context: living conditions, family situation, activity.
–Date of last menstrual period.Trimester Month Weeks LMP*Consultation
schedule
First1
232-56-9
10-13
⇐Consultation 1
Second456 14-1718-2122-26⇐Consultation 2
Third789 27-3031-35
36-40/41⇐Consultation 3
⇐Consultation 4Diagnosing and moni toring pregnancy
191

– Obstetric and surgi cal history:
• Number of prior pregnancies;
• Complications with prior pregnancies/deliverie s (haemorrhage, infection, prematurity,
etc.);
•Spontaneous or i nduce d abortion(s);
• Children, alive and deceased;
• Cae sarean section (find out why) or any other uteri ne surgery;
• Instrumental del ivery;
• Vesicovaginal or rectovagi nal fistula.
– Medical history and ongoing treatments: hypertension, diabetes, asthma, epilepsy, heart
disease, HIV infection, psychiatric disorder, etc.
– Immunisation status (te tanus).
– Current problems: pelvic pain, contractions, fever, urinary symptoms, vaginal bleeding,
etc. If there are signs of a sexually transmitted infection (STI) – e.g., abnormal vaginal
discharge or urethral discharge – always look for other concurrent STIs.
B. Estimating the gestational ageand due date
The gestational age is estimated by counting the numbe r of weeks since the last menstrual
period (weeks LMP) using a calendar or pregnancy wheel.
For example, if the last menstrual period was on 15 December 2014 and the woman is seenon 27 January 2015, the estimated gestational age is 6 weeks LMP.Always verify that this estimate tallies with the data from the clinical examination (estimateof uterine size) or the ultrasound.
The due date is estimated by counting 40 or 41 weeks from the first day of the last
menstrual period.For example, if the date of the last menstrual period was 15 December 2014, the due date isbetween 22 and 29 September 2015.
The due date can also be estimated by counting 9 months plus 7 to 14 days from the first
day of the last menstrual period. If the woman does not know the date of her last menstrual period, the presumed gestational
age and due date is determined based on clinical examination or ultrasound
b.
C. Clinical examination
In all cases:– Weight; blood pressure (patient seated and resting).– Height (only for women < 1.40 m).–Look for abdominal scar.–Look for anaemia, oedema, etc.–Look for foetal heart tone starting at the end of the first trimester.
– Estimate the size of the uterus (gives an estimate of gestational age):
• During the first trimester, the size of the uterus is estimated by bimanual examination.
At 7 weeks the uterus is the size of a chicken egg, at 10 weeks the size of an orange,
and at 12 weeks the uterine fundus extends beyond the symphysis pubis.
• Starting in the second trimester, the uterus can be felt by abdominal palpation alone;
measure the fundal height, which is the distance between the upper edge of the
symphysis pubis and the fundus (Figure 1.1).
bUltrasound allows accurate estimation of gestational age in the first trimester, with a margin of error of
approximately 7 days. The margin of error is larger in the second and third trimesters (about 15 and
20 days, respectively).Chapter 1
20

Figure 1.1
Measuring the fundal height
The estimate of the gestational age becomes increasingly approximate as the pregnancy
advances. As a rough gui de:
Table 1.3 – Fundal hei ghtaccording to gestati onal age
Note: fundal height and uterine growth may vary with ethnicity. Use the national curves
from the Mi nistry of Heal th, if they exist.
Only if indicated:
– Genital exami nation (e.g., to look for muti lation, if complaint of abnormal di scharge, etc.).
– Vaginal exami nation (e.g., if there is doubt about the pregnancy di agnosis).
D. Laboratory tests
Table 1.4 – Recommended screening tests!
Fundal height Weeks since last menstrual period
20 cm 18 – 22 weeks LMP
24 cm 22 – 26 weeks LMP
28 cm 26 – 30 weeks LMP
32 cm 30 – 34 weeks LMP
34 cm 33 weeks LMP to te rm
Tests Comments
Syphilis Syphilis screening should be done at the first consultation, as early as
possible in pregnancy . If it was not done at an antenatal consultation, it
should be done at delivery.
Use a Treponema-specific rapid test (e.g., SD Bioline®).
Malaria In endemic areas, perform a rapid test even if there are no symptoms.
HIV infection Offer a test to all women who do not know their HIV status. Perform
rapid tests according to the standard algorithm. Testing cannot be
done without the patient’s consent.Evaluate the immunological status (CD4 count): as soon as possibleafter seropositivity is detected, or at the first antenatal consultation
for women who already know that they are HIV positive.Diagnosing and moni toring pregnancy
211

Table 1.4 – Recommended screening tests (contnued)
E. Antenatal carecard
Fill an individual card contai ning information for moni toring the pregnancy (Appendix 1).
1.2.4 Subsequent consultations
A. Interview
– Foetal movement fe lt by the mothe r.
– Current problems: pelvic pain, contractions, fever, urinary symptoms, abnormal vaginal
discharge, metrorrhagia, etc.
B. Clinical examination
Be careful when examining a woman lying on her back ; the weight of the uterus compresses
the inferior vena cava, which can cause her to feel faint (easily remedied by placing the
patient on her l eft side).
In all cases:
– Blood pressure, wei ght, oedema, fundal he ight.
– Foetal heart tone: should be regular, rapid (120-160/minute), and out of sync with the
mother’ s pulse.
– Foetal presentation (third tri mester):
Palpation:
• Cephalic pole: round, hard and regular; there should be a feeling of ballottement
between examiner’ s hands; separate d from the rest of the body by the indentation of
the neck, beyond which the proje ction of the shoulder can be pal pated.
• Pelvic pole: soft; bul kier and l ess regular than the cephal ic pole; no neck i ndentation.
Types of presentation:• Cephalic: the cephal ic pole points towards the mother’s pel vis.
•Breech: the cephal ic pole is in the uterine fundus.
•Transverse: the poles l ie in each of the mother’s si des.
– Exploring the foetal back:
Press the uterine fundus downward to bend the foetal spine and explore the lateral
surfaces of the uterus. The back is felt as a hard plane, the limbs as small, irregular
projections. The back is described with reference to the mother’s right or l eft.
–In the third trimester, the foetal heart tone is auscultated in the umbilical region along the
foetus’ back, at shoulder l evel.
Only if indicated:– Genital exami nation (e.g., if mother compl ains of abnormal di scharge).
– Vaginal exami nation (e.g., if mother compl ains of recurring uterine contracti ons).Tests Remarques
Anaemia Measure haemogl obin (HemoCue).
Urinary tract
infectionTest for asymptomatic bacteriuria, even if there are no symptoms
(urinalysis with reagent test stri ps).Chapter 1
22

Note: the vaginal examination is sometimes used to evaluate the pelvic dimensions in small
primiparas. A small pelviscis not necessarily predictive for foeto-pelvic disproportion (FPD)
and does not justify scheduling a caesarean section. Moreover, FPD can occur with a
normal-appearing pel vis. In practi ce, FPD can only be establ ished during l abour.
C. Laboratory tests
Table 1.5 – Recommended screening tests
1.2.5 Preventive treatments
Maternal and neonatal tetanus
– Pregnant women not vaccinated against tetanus in childhood or adolescence should
receive at least 2 doses of tetanus vaccine (TT) before gi ving birth:
•the first dose should be admi nistere d at the first consul tation;
•the second dose should be administered at least 4 weeks after the first dose and ideally
at least 2 weeks before the due date to maximize the maternal antibody response and
passive antibody transfer to the infant.
– After the birth, continue to a total of 5 doses, according to the schedule below. Once
administered, these 5 doses confer l ifelong protection.
Table 1.6 – Vaccination schedule for women who are pregnant or of chi ld-bearing age3
cThe pelvis is considered small if the top of the sacrum (promontory) can be reached with the fingers and/or
the lateral edges of the pelvis can be felt along their entire length.Tests Comments
Urinary tract
infectionLook for asymptomatic bacteriuria at each consultation.
Malaria In endemic areas, perform a rapid test at each consultation, unless the
woman was tested in the past 4 weeks, the test was positive, and the
woman received curative antimalarial treatment as a result.
HIV infection Offer patients who tested negative during the 1sttrimester a new test
in the third trimester. There is increased risk of transmission when
seroconversion occurs during pregnancy.
Dose When to giveLevel of
protection
TT1At the first contact with medi cal services
or as early as possible during pregnancy0%
TT2At least 4 weeks after TT1and at least 2 weeks before the delivery due date80%
TT3At least 6 months after TT2or during the next pregnancy95%
TT4At least 1 year after TT3or during another pregnancy99%
TT5At least 1 year after TT4or during another pregnancy99%Diagnosing and moni toring pregnancy
231

Anaemia
–If there are no cl inical signs of anae mia and no abnormal hae moglobin val ues:
1) Administer iron and folic acid supplementation, starting as soon as possible after
gestation starts and conti nuing for the rest of the pregnancy. Give e ither:
ferrous sulfate/folic acidd(tablet containing 200 mg of ferrous sulfate, 65 mg of
elemental iron + 400 micrograms of fol ic acid) PO: 1 tabl et/day
or
multiple micronutrientse(tablet containin g 93.75 mg of ferrous sulfat e, equivalent to
30 mg of elemental iron + 400 micrograms of folic acid + other nutrients) PO:
1tablet/day
Note: the World Health Organization recommends 30 to 60 mg of elemental iron daily
however, a dose of 60 mg of elemental iron daily is preferred over a dose of 30 mg
daily in se ttings where pre valence of anaemia in pregnant women is high (≥ 40%)f,4.
2)In areas where hookworm is endemic, administer also an antihelminthic treatme nt as
of the second tri mester:
albendazole PO: 400 mg as a si ngle dose (or mebendazole PO: 500 mg as a si ngle dose)
3) In areas where malaria is endemic, administer also an intermittent preventive
antimalarial treatme nt or an antimalarial curative treatment, depending on the results
of malaria scree ning test (see be low).
–If there is clinical evidence of anaemia (pallor of the palms, conjunctivae or tongue) or if
haemoglobin is < 11 g/dl : see Chapter 4, Se ction 4.1.
Malaria
In areas with moderate to high falciparum malaria transmissiongin Africa, prevention
consists of:
1)The use of i nsecticide-treate d mosquito nets (2 bed nets should be provi ded);
2) Malaria testing at each antenatal consul tation:
–If the test is ne gative, as of the second tri mester:
Administer an intermittent preventive treatment with sulfadoxine-pyrimethamine
(SP)5. Allow an interval of at least one month be twee n two treatme nts.
This treatment helps reduce the effects of malaria (maternal anaemia and low birth
weight). The SP dose for each treatment is 3 tablets as a si ngle dose.
Do not administer intermittent treatment with SP to HIV-infected women receiving
cotrimoxazole prophylaxis.
–If the test is posi tive, throughout pregnancy:
Administer curative mal aria treatment (Chapter 4, Se ction 4.3.1).
Wait one month after curative treatment before screening for mal aria again.
d200 mg ferrous sulfate (65 mg elemental iron) + 400 micrograms folic acid tablets may be replaced by
185 mg ferrous fumarate (60 mg el emental iron) + 400 micrograms fol ic acid tablets. eIf using multiple micronutrients, make sure that the amount of iron salts (sulfate or fumarate) is equivalent
to 30 mg of elemental iron per tablet and the amount of folic acid is 400 micrograms per tablet
(UNU/UNICEF/WHO formulation). For the complete composition of these tablets, see Medical catalogue ,
MSF.fAccording to the World Health Organization (1993-2005), the prevalence of anaemia in pregnant women is
57.1% for Africa, 48.2% for South-East Asia, 44.2% for the Eastern Mediterranean region, 30.7% for the
Western Paci fic region, 25% for the European region and 24.1% for the Americas. g“Moderate transmission” areas: zones where prevalence rate of malaria is 11–50% during most of the year
among children 2–9 years. “High transmission” areas: zones where prevalence rate of malaria is over 50%
during most of the year among chi ldren 2–9 years.Chapter 1
24

Urinary tract infection
Treat asymptomatic bacteriuria to reduce the risk of pyelonephritis6(Chapter 4, Section 4.2.6 ).
HIV infection
To prevent mother-to-child transmission, administer antiretroviral therapy to the mother
(Chapter 4, Se ction 4.4.4).
Vitamin and micronutrient deficiencies
– Vitamin K 1
For women being treated with an enzyme inductor (e.g. rifampicin, rifabutin; carbamazepine,
phenobarbital, phenytoin), administer phytomenadione PO: 10 mg/day in the 15 days
preceding the due date.
– Calcium
Supplementation is recommended for7:
• All pregnant adolescents (less than 20 years);
• All pregnant women with low calcium intake AND at high risk of pre-eclampsia (history
of pre-eclampsia or eclampsia, twin pregnancy, chronic hypertension).
Start supplementation before 20 weeks LMP and continue throughout the pregnancy:
calcium carbonate PO: one 1.25 g tablet (equivalent to 500 mg of calcium element)
3 times per day (= 1500 mg cal cium element dai ly in 3 divided doses).
Wait two hours between the admi nistration of cal cium and ferrous salts.
– Vitamin D
Some nati onal protocols may i nclude vitamin D to prevent ne onatal hypocal caemia:
ergocalciferol (vitamin D2) or colecalciferol (vitamin D3) PO: 100 000 IU as a single dose in
the sixth or seventh month of pre gnancy.
– Iodine
Iodine deficiency during pregnancy increase s the risk of miscarriage, prematurity, severe
mental and growth retardation in the child, and neonatal or infant death. In areas where
iodine deficiency is endemic, iodine supplementation is necessary. Follow national
protocol.
Malnutrition
–Even in absence of signs of mal nutrition, food suppl ementation is recommended:
•For all pregnant women throughout their pregnancy in si tuations where food is scarce;
•For all pregnant adolescents (less than 20 years).
– If there are clinical signs of malnutrition, place the woman into a therapeutic feeding
programme.
Others
The above measures apply to most contexts. Other tests and preventive measures relevant
in a specific context or included in the national protocol (e.g. Rhesus factor testing and allo-
immunization prophyl axis, screening for cervi cal cancer) should be taken into account. Diagnosing and moni toring pregnancy
251

1.2.6 Preparation for the birth
Group sessions
Group sessions (10 to 15 women) should be organized to encourage information sharing
between patients, promote the use of available services and weigh upon:
–Importance of ski lled birth assi stance.
–The purpose of ante natal consul tations.
– The recommended tests and treatments during pregnancy (screening tests, tetanus
vaccination and pre vention of mother-to-chi ld HIV transmi ssion, etc.).
– Danger signs during pregnancy and delivery, and the importance of quickly seeking
medical care .
–The use of i nsecticide-treate d mosquito nets.
–The use of the “birth ki t”h, depending on the context.
–The purpose of the postnatal consultation.
Individual sessions
Individual sessions are an opportunity to revisit the subjects discusse d in the group sessions
and offer advice tailored to the individual's medical and social situation.
The choice of topics depends on the stage of pregnancy and the woman’s specific circumstances:
– Birth plan (see below).– Danger signs during pregnancy and delivery, and the importance of quickly seeking
medical care.
– Contraception, especially for grand multiparas and women at high obstetrical risk.
Birth plan
With the patient, work out a personalised plan appropriate to her medical and social
situation: – Preferred site for birth: CEmONC or BEmONC facility, depending on the course of the
pregnancy and the hi story;
–Any necessary arrangements: transportati on, family arrange ments, etc.
Table 1.7 – Obstetric care faci lities
hIndividual kit given to women that might deliver at home due to limited travel possibility (remote or insecure
situations). It contains a plastic-coated cloth to be spread out on the floor (for cleaning the woman’s genitals
and washing the midwife’s hands), a string and a razor blade for tying and cutting the cord and, in some cases, a
cloth for drying the infant.Facility Minimum package
BEmONC
Basic Emergency
Obstetric and Newborn
Care• Ope n 24/7
• Skilled birth atte ndant(s)
• Possibility of:
– parenteral antibiotics- uterotonics- anticonvulsants if pre-eclampsia or eclampsia
• Possibility of:
– manual removal of the placenta – uterine evacuation (vacuum aspiration)- instrumental delivery (vacuum extraction)
– basic neonatal resuscitation
CEmONCComplete EmergencyObstetric and Newborn
Care•Same as BEmONC faci lity
PLUS• Possibility of:
– surgical management (caesarean secti on, hysterectomy, etc.)
– blood transfusi onChapter 1
26

1.3 Monitoring complicated pregnancies
The term “complicated” refers to pregnancie s in which the mother or infant is at increased
risk due to a parti cular obstetric or medi cal pathology or history.
Complicate d pregnancies may require highe r level monitoring and/or special arrangements
for delivery in a me dical/surgical setting.
1.3.1 Situations requiring higher level monitoring
In the following situations, the increased risk exists mainly during pregnancy itself rather
than delivery:
– History of preterm de livery or mul tiple miscarriages (ri sk of recurrence).
– History of unexpl aine d ante-partum i ntrauterine foe tal death.
– Progressive associated pathology such as upper urinary tract infection (risk of preterm
delivery), anaemia (possi ble exacerbation), hypertension, pre-eclampsia, etc.
1.3.2 Situations requiring special precautions for delivery
In the following situations, the increase d risk exists mainly during de livery rather than duri ng
pregnancy.
Arrange for delivery in a BEmONC facility:
– History of intra-partum intrauterine foetal death or death in the first day of life (risk of
recurrence).
– History of haemorrhage during a prior del ivery (risk of recurrence and maternal death).
– History of forceps or vacuum del ivery (risk of re currence).
– Height less than 1.40 m (risk of foeto-pel vic disproportion).
– Primiparity (ri sk of obstructed l abour).
– Limp, hip dislocation, polio sequelae with frank pelvic asymmetry (risk of obstructed
labour).
– Grand multiparity (risk of uterine rupture, uterine atony, uterine atony-related
haemorrhage).
Note: it is essential that all maternity hospitals without an operating room have an effective
system for referring patients to a CEmONC faci lity.
Arrange for delivery in a CEmONC facility:–In situations that routi nely require caesarean secti on:
• History of uterine rupture.
• History of caesarean with verti cal (classical) incision or more than two caesarean bi rths.
•Transverse l ie.
A planned caesarean should be done at 39 weeks LMP or later. Before 39 weeks LMP,
caesarean births without labour – even when not premature (37-38 weeks LMP) – are
associated with a high risk of neonatal respiratory distress. That risk exists regardless of
the estimated foetal weight. Diagnosing and moni toring pregnancy
271

When the due date is unce rtain:
•If there is a very high risk of uterine rupture (e.g., history of severe uterine rupture or
more than three prior caesarean sections), consider scheduling a caesarean section
prior to labour during the ninth month, with preparation for managing neonatalrespiratory distress.
•In other cases it is better to wait until the woman goes into labour to do the caesarean
section. Under those circumstances, if the patient lives far away, suggest that she movenear the facility where she will deliver during her ninth month, either with family or at aresidential facility (maternity waiting home).
–In situations where there is a high risk that eme rgency caesare an or complex obstetrical
manoe uvres will be neede d:
• History of low ute rine segment transverse i ncision;
• History of uterine scar (perforated uterus or myomectomy);• History of vesi co-vaginal fi stula;
• History of symphysi otomy;
• History of third or fourth degree te ar;
•Breech presentation.
1.3.3 Situations requiring higher level monitoring during pregnancyAND special precautions for delivery (CEmONC)
– History of abruptio placentae, severe pre-eclampsia or eclampsia (for secondary
prophylaxis with aspi rin, Chapter 4, Se ction 4.5.6).
– Pre-eclampsia (risk of eclampsia, coagulopathy, maternal death, abruptio placentae,
intrauterine growth retardati on, intrauterine foe tal death) or e clampsia.
– Bleeding (risk of preterm delivery, foetal distress, intrauterine foetal death, anaemia,
maternal death).
– Severe anaemia (risk of small foetus, prematurity, neonatal anaemia, increased
vulnerability in case of haemorrhage). Transfusion should be available in case of severe
anaemia during the third tri mester.
– Multiple pregnancy (risk of obstructed labour, prete rm delivery, hypertension, diabetes,
intrauterine growth retardation and postpartum haemorrhage). Advi se rest.
– Premature rupture of membranes (risk of infection, preterm delivery and intrauterine
foetal death).Chapter 1
28

References
1World Health Organization. WHO Antenatal Care Randomised Trial: Manual for the
Implementation of the New Mode l. Geneva. 2002. WHO/RHR/01.30.
http://whqlibdoc.who.int/hq/2001/WHO_RHR_01.30.pdf
2World Health Organization. Standards for maternal and neonatal care: prevention of
mother-to-child transmission of syphilis, 2006.
http://www.who.int/reproductivehealth/publications/maternal_perinatal_health/prevention
_mtct_syphilis.pdf
3World Health Organi zation. Field manual for neonatal tetanus e limination. Geneva. 1999.
http://whqlibdoc.who.int/hq/1999/WHO_V&B_99.14.pdf
4World Health Organization. Guideline: Daily iron and folic acid supplementation in pregnant
women. Geneva. 2012.
http://apps.who.int/iris/bitstream/10665/77770/1/9789241501996_eng.pdf
5WHO policy brief for the implementation of intermittent preventive treatment of malaria
in pregnancy using sulfadoxine-pyrimethamine (IPTp-SP). April 2013 (revised January
2014).http://www.who.int/malaria/publications/atoz/iptp-sp-updated-policy-brief-24jan2014.pdf
6Smaill F, Vazquez JC. Antibiotics for asymptomatic bacteriuria in pregnancy (Review). The
Cochrane Library 2007, Issue 4.
http://apps.who.int/rhl/reviews/CD000490.pdf
7World Health Organi zation. Cal cium suppl ementation in pregnant women. 2013.
http://apps.who.int/iris/bitstream/10665/85120/1/9789241505376_eng.pdfDiagnosing and moni toring pregnancy
291

Chapter 2:
Bleeding during the first half of pregnancy
2.1 Abortion ……………………………………………………………………………………………………33
2.1.1 Diagnosis …………………………………………………………………………………………..33
2.1.2 Differential diagnosis ………………………………………………………………………….33
2.1.3 Management ……………………………………………………………………………………..33
2.2 Ectopic pregnancy ……………………………………………………………………………………..36
2.2.1 Diagnosis …………………………………………………………………………………………..36
2.2.2 Differential diagnosis ………………………………………………………………………….37
2.2.3 Management ……………………………………………………………………………………..37
2.3 Molar pregnancy (hydatidiform mole) …………………………………………………………38
2.3.1 Diagnosis …………………………………………………………………………………………..38
2.3.2 Management ……………………………………………………………………………………..38
2.3.3 Follow-up …………………………………………………………………………………………..39
2.4 Cervicitis …………………………………………………………………………………………………..40
2.4.1 Diagnosis …………………………………………………………………………………………..40
2.4.2 Management ……………………………………………………………………………………..40
2.5 Functional bleeding ……………………………………………………………………………………41
2.5.1 Diagnosis …………………………………………………………………………………………..41
2.5.2 Management ……………………………………………………………………………………..412

2.1 Abortion
Spontane ous or induced i nterruption of pregnancy before 22 weeks LMP.
In countries where voluntary termination of pregnancy is legally restricted, induced
abortions are often performed under poor conditions (inappropriate substances, non-sterile equipment, without qualified health care personnel, etc.). Complications from suchabortions (trauma, bleeding and severe infection) are common and may be life-threatening.For safe abortion care, see Chapter 12.
2.1.1 Diagnosis
Signs and symptoms
– Threatene d abortion or missed abortion: l ight bleeding, abdominal pain, closed ce rvix.
– Incomplete abortion: more or less severe bleeding, abdominal pain, uterine contractions,
expulsion of products of conception, open cervi x.
–Trauma to the vagina or cervix or the presence of a foreign body are strongly suggestive
of unsafe abortion. Look for compl ications, especially i nfection.
Additional tests
–A pregnancy test is use ful if the history and cl inical examination are i nconclusive.
– Ultrasound is useful for confirming pregnancy termination or the presence of retained
products of conce ption after i ncomplete abortion.
2.1.2 Differential diagnosis
The main differential diagnoses are: ectopic pregnancy, cervicitis, cervical ectropion
(eversion of the cervical mucosa, which is more fragile and may bleed easily on contact,
especially after a vaginal examination or sexual relations), cervical polyp, and functional
uterine bl eeding.
2.1.3 Management
Threatened abortion
– Advise the patient to reduce activity. Either the threat of abortion recedes, or abortion is
inevitable.
–Look for a possible infectious cause (malaria or sexually transmitted infections) and treat
it.
–Treat pain according to severi ty.Bleeding during the first half of pregnancy
332

Ongoing or incomplete abortion
– Measure pulse, blood pressure, temperature; assess severity of bl eeding.
–Treat pain according to severi ty.
– Remove any visible products of conception from the vagina and ce rvix.
– Remove foreign bodies, if present, clean the wound, and check and/or update tetanus
immunisation (Table 2.1).
Table 2.1 – Tetanus prophyl axis
–For septic abortion (fever, abdomi nal pain, tender uterus, foul -smelling di scharge ), add:
amoxicillin/clavulanic acid IV (dose expressed in amoxicillin): 3 g/day in 3 divided doses
administere d 8 hours apart + gentamicin IM: 3 to 5 mg/kg once dai ly
or
ampicillin IV: 6 g/day in 3 divided doses administered 8 hours apart + metronidazole IV:
1.5 g/day in 3 divided doses administered 8 hours apart + gentamicin IM: 3 to 5 mg/kg
once daily
Continue for 48 hours (until the fever disappears), then change to:
amoxicillin/clavulanic acid PO (dose expressed in amoxicillin): 3 g/day in 2 to 3 divided
dosesato complete 5 days of treatment
or
amoxicillin PO: 3 g/day in 3 divided doses + metronidazole PO: 1.5 g/day in 3 divide d doses
to complete 5 days of treatmentFor very severe infection (infected perforated uterus or peritonitis), treat for 10 days.
aThe daily dose should be given in 2 divided doses if using the 8:1 or 7:1 formulation, and in 3 divided doses
if using the 4:1 formulation.Immunisation status Spontaneous abortionUnsafe abortion,
with wound or foreign body
Not immunised
or Immunisation statusunknown Begin immunisation agai nst
tetanusBegin immunisation agai nst
tetanus+ Human tetanus i mmunoglobulin
Incompletely immunised Tetanus booster Tetanus booster + Human tetanus i mmunoglobulin
Fully immunised
Last booster dose:
< 5 years
5 to 10 years> 10 yearsNo prophyl axis
No prophylaxisTetanus boosterNo prophyl axis
Tetanus boosterTetanus booster
+Human tetanus i mmunoglobulinChapter 2
34

–If bleeding is heavy:
•Insert an IV l ine (16-18G catheter) and admi nister Ringer l actate;
• Closely monitor pul se, blood pressure , bleeding;
• To prepare for a possible transfusion, determine the patient’s blood type and select
potential donors or make sure that blood is available. If transfusion is necessary, only
use blood that has been screened (HIV-1, HIV-2, hepati tis B, hepati tis C and syphi lis).
– Uterine evacuati on:
Before 10 weeks LMP:
Expulsion is often compl ete; uterine evacuation is usual ly not necessary.
Monitor blood loss; do not evacuate the uterus unless bl eeding is heavy.
Between 10 and 12 to 14 weeks LMPb:
Uterine evacuation is usually required due to retained products of conception, which cancause bleeding and infection. If uterine evacuation is necessary, there are three options:• Instrumental methods:
– manual vacuum aspiration (Chapter 9, Section 9.5) or – instrumental curettage (Chapter 9, Section 9.6).
Aspiration under local anaesthesia is the method of choice
1. It is technically easier to
perform, less traumatic and less painful than curettage.
• Medical method:
The use of misoprostol as a single dose (400 micrograms sublingually or
600 micrograms PO)2,3may avoid surgi cal intervention.
There is, however, a risk of failure that increases as the pregnancy progresses.
Treatme nt succe ss (that is, an empty uterus) must be verifie d in the days after the drug
is taken. If the medi cal method fai ls, the use of an i nstrumental method is unavoi dable.
Beyond 12 to 14 weeks LMP: Be patient; leave the amniotic sac intact and allow labour to take its course. The placenta
is usually expelled with the foetus. Part of the place nta may be retained. If examination of
the placenta leaves any doubt, or in the event of haemorrhage, rapidly perform digital
curettage after the expulsion. If delayed, this procedure becomes impossible due to
retraction of the cervix. At that point, instrumental curettage –with its significant risk of
uterine perforation– may become necessary (Chapte r 9, Section 9.6).
– Afterward, provide iron + folic acid supplementation or, in case of severe anaemia, a
blood transfusi on.
–Look for a possible infectious cause (malaria or sexually transmitted infections) and treat
it.
bThe gestational age is based on the date of last menstrual period and uterine size. Uterine evacuation, using
aspiration or misoprostol are usually recommended up to 12 weeks. The estimation of gestational age is
often approximative. Thus, these methods can be used up to an estimated gestational age of 14 weeks.Bleeding during the first half of pregnancy
352

2.2 Ectopic pregnancy
Implantation of the fertilized egg outside of the uterine cavity, usually in the distal two
thirds of the Fallopian tube. Other locations are rarer. Predisposing factors are history of
peritonitis or pel vic infection.
2.2.1 Diagnosis
Signs and symptoms
Symptoms that are the same re gardle ss of the l ocation of the ectopic pregnancy:
– History: rece nt history of intermitte nt abdominal pain, a few wee ks of amenorrhea, then
vaginal bleeding or menstrual irregularity, nausea and vomiting, occasional dizziness or
faintness.
– Examination: abdominal tenderness of varying severity, guarding, occasional adnexal
mass, cervical and posterior fornix tende rness.
In the event of tubal pregnancy:
– Blood may collect in the Fallopian tube (haematosalpinx). The symptoms above may then
be more severe and prol onged, with a pai nful adnexal mass.
– Bleeding may gradually seep into the abdominal cavity over several days or wee ks. The
blood accumulates in the Pouch of Douglas and form a haemato ma (haematocele). If a
haematocele forms – espe cially if it is large – there may be other signs and symptoms:
• irritation of the bladder or rectum with pollakiuria, dysuria, rectal cramps and low
grade feve r;
• bulging and increased pain in the posterior fornix, with a pelvic mass with poorly-
defined borders and uneven consistency that pushes the uterus forward;
• anaemia.
In the event of sudden Fallopian tube rupture, the tube’ s blood vessels are often damaged.
A haemoperitone um (bloody effusion into the peri toneal cavity) develops qui ckly.
On examination:
– distended, tender abdome n, shifting dullness;
– exquisite pain in the Pouch of Dougl as;
– scapular pai n;
– hypovolaemic shock due to bleeding (rapid, weak or unmeasurable pulse, very low or
unmeasurable blood pressure, tachypnoea, pallor, cold sensation, damp skin, agitation
and anxiety).
In general, a cervical pregnancy (very rare) most closely resembles an incomplete abortion.
It is often discovered due to massive bleeding during vacuum aspiration or curettage to
evacuate the uterus.
Additional tests
–Pregnancy test: the test is usually positive in ectopic pregnancy; in case of haematocele,
however, it may be negati ve.
– In all cases, ultrasound shows an empty uterus, and in some cases an adnexal mass
(haematosalpinx or haematocele) or fluid/blood in the abdominal cavity (haemo –
peritoneum).
If ultrasound is unavailable and there is still some doubt, culdocentesis (Pouch of Douglas
puncture) may be useful to look for a haemoperitoneum. The procedure is pointless when
laparotomy is cl early indicated.Chapter 2
36

– Culdocentesis:
• General (ketamine) or local (1% lidocaine) anaesthesia.
•Swab the perineum, vagina and cervix with 10% polyvidone iodine.•Pouch the posterior vaginal wall down using a speculum. Grasp the posterior lip of the
cervix with Pozzi forceps and lift the cervix upward.
•Puncture the posterior fornix using a large calibre needle held as close to horizontal as
possible, and aspirate with a 20-ml syringe.
•An aspirate containing non-clotting blood is indicative of intra-peritoneal bleeding.
Figure 2.1
Puncture of the posterior fornix
2.2.2 Differential diagnosis
The main differential diagnoses for ectopic pregnancies are abortion, salpingitis, ovarian
abscess, appendicitis and di verticulitis.
When haematocele is suspected, also conside r pyosalpinx, fibroma, or pelvic abscess from
anothe r cause.
When haemoperitoneum is suspected, also consider gastric or duodenal perforation,
ovarian cyst rupture or ovarian torsi on.
2.2.3 Management
When the di agnosis of ectopic pregnancy is hi ghly likely:
–Prepare for laparotomy or refer urgently to a CEmONC faci lity.
–Insert an IV l ine (16-18G catheter) and admi nister Ringer l actate.
– Closely monitor pul se, blood pressure and bl eeding.
– To prepare for a possible transfusion, determine the patient’s blood type and select
potential donors or make sure that blood is available. If transfusion is necessary, only use
blood that has been screened (HIV-1, HIV-2, hepati tis B, hepati tis C and syphi lis).
Special cases:–In the event of massive bleeding during vacuum aspiration or curettage for what turns out
to be a cervical pregnancy, temporarily stop the bleeding, if possible, using intracervical
Foley catheter compression or cerclage before consi dering total hysterectomy.
– Abdominal pregnancy is treated by laparotomy. Depending on its location, removing the
placenta may be very difficult and cause severe bleeding; in that case, leave the placenta
in place.!
!
!
!
!
!
Bleeding during the first half of pregnancy
372

2.3 Molar pregnancy (hydatidiform mole)
Pathological pregnancy due to cystic degeneration of the placenta (abnormal proliferation
of the chorionic villi). The mole presents in the form of translucent vesicles, 1 to 2 cm in
diameter, connected by filaments like a cluster of grapes. In most cases there is neither
foetus nor amni otic sac.
2.3.1 Diagnosis
Signs and symptoms
– Spontane ous bleeding of vari able severity.
– Ute rus large r and softer than expected for gestati onal age.
– No foetal heart tone, movements, or pol es at five months.
– Nausea and vomi ting that is more frequent and lasts longer than in a normal pregnancy.
– Occasionally:
• Oedema, proteinuria, or hyperte nsion if the pregnancy is advanced;
• Enlarge d ovaries, weight loss, mild jaundice;
• Slow, fragmentary, incomplete abortion, and occasionally accompanied by heavy
bleeding with expul sion of vesi cles.
Additional tests
–The pregnancy test is always posi tive.
– Ultrasound shows a heterogeneous, vesicular placenta filling the entire uterine cavity.
2.3.2 Management
– Re fer to a CEmONC faci lity: risk of bl eeding and compl icated uteri ne evacuation.
– Inse rt an IV line (16-18G catheter) and admi nister Ringer l actate.
– Closely monitor pulse, blood pressure and bleeding.
– To prepare for a possible transfusion, determine the patient’s blood type and select
potential donors or make sure that blood is available. If transfusion is necessary, only use
blood that has been screened (HIV-1, HIV-2, hepatitis B, hepatitis C and syphilis).
– Evacuate the mole using suction, digital curettage, or careful instrumental curettage
(Chapter 9). The evacuation should be done under oxytocin, 20 IU in 1 litre of Ringer
lactate or 0.9% sodium chloride administered over 2 hours (160 drops/minute) to prevent
bleeding and reduce the risk of perforation (the uterine wall is thin and weakened). No
debris should remain after uterine evacuation. If possible, perform an ultrasound to make
sure the uterus is empty.
– Contraceptives, preferably hormonal , for at least one year, or tubal l igation if desi red.Chapter 2
38

2.3.3 Follow-up
In approximately 10 to 15% of patients, the mole develops into persistent trophoblastic
disease or choriocarcinoma.
See the pati ent:
–2 wee ks after the evacuation, if possible, perform an ultrasound to make sure the uterus
is empty. If ultrasound is unavailable and bleeding persists, consider a second aspiration
(eve n when done correctly, re tention of molar debris is not uncommon).
–8 weeks after the evacuation: perform the first follow-up pregnancy test. The pregnancy
test does not become negative immediately after the evacuation, but it should be
negative within 8 we eks.
If the test is negative, perform a pregnancy test every 4 to 8 weeks for 1 year.
If it is positive after 8 weeks or becomes positive during subsequent follow-up despite
effective contraception, refer the patient to rule out or treat persistent trophoblastic
disease or choriocarcinoma.Bleeding during the first half of pregnancy
392

2.4 Cervicitis
Inflammation of the cervix caused by a number of infectious agents – Chlamydia
trachomatis and Neisseria gonorrhoeae in more than 40% of cases.
2.4.1 Diagnosis
– Light bl eeding.
– Cervix red, inflamed, infected (purulent discharge).
– Possible associated vaginitis (foul-smelling vaginal discharge).
2.4.2 Management
Antibiotics active against chlamydia and gonococcus for the patient and her partner
(Chapte r 4, Section 4.2.5).
A red, inflammatory and deformed cervix may indicate a more serious lesion (dysplasia or
cance r). Do not, however, jump to the conclusion that it is a malignant lesion, because the
appearance of the cervix can change during pregnancy (as with a severe ectropion). If in
doubt, see the patient again 3 months after de livery to re-e xamine the ce rvix.Chapter 2
40

2.5 Functional bleeding
Bleeding that is usually light, endometrial in origin, with no apparent cause. This is a
diagnosis of exclusion, after the other causes of bleeding discussed in this chapter have
been ruled out.
2.5.1 Diagnosis
– Light bl eeding.
– Normal size uterus; long, closed posterior cervix; no adnexal mass.
2.5.2 Management
Rest; no medi cation indicated.Bleeding during the first half of pregnancy
412

References
1Cochrane Pregnancy and Childbirth Group. Özge Tunçalp, A Metin Gülmezoglu, João
Paulo Souza. Surgical procedures for evacuating incomplete miscarriage. Published
Online : 8 SEP 2010. Assessed as up-to-date: 25 JUL 2010.
2World Health Organization. Clinical practice handbook for safe abortion. Geneva, 2014.
http://apps.who.int/iris/bitstream/10665/97415/1/9789241548717_eng.pdf
3Gynuity health projects. Misoprostol for treatment of incomplete abortion: An
introductory gui debook, 2009.
http://gynuity.org/downloads/clinguide_pacguide_en.pdfChapter 2
42

3Chapter 3:
Bleeding during the second half ofpregnancy
3.1 Placenta praevia ………………………………………………………………………………………..45
3.1.1 Different types of placenta praevia ……………………………………………………….45
3.1.2 Diagnosis …………………………………………………………………………………………..45
3.1.3 Management ……………………………………………………………………………………..46
3.2 Abruptio placentae …………………………………………………………………………………….48
3.2.1 Diagnosis …………………………………………………………………………………………..48
3.2.2 Management ……………………………………………………………………………………..48
3.3 Uterine rupture …………………………………………………………………………………………50
3.3.1 Circumstances in which uterine rupture occurs ……………………………………….50
3.3.2 Diagnosis …………………………………………………………………………………………..50
3.3.3 Management ……………………………………………………………………………………..52
3.4 Diagnosis of bleeding during the second half of pregnancy (summary) ……………54

3.1 Placenta praevia
Abnormal implantation of the placenta in the lower uterine segment, rather than in the
uterine fundus.
The primary risk factors for placenta praevia are multiparity and a history of caesarean
section.Even under good circumstances (possibility of blood transfusion, high quality surgical
setting), maternal and foetal mortal ity and the ri sk of postpartum haemorrhage are high.
3.1.1 Different types of placenta praevia
There are four types of pl acenta praevia:
–Complete placenta praevia (Figure 3.1a), in which the placenta completely blocks the
internal cervical os;
–Partialplacenta praevia, in which the placenta partially blocks the internal cervical os;
In either of these cases, vagi nal delivery is not possi ble.
–Marginal placenta praevia (Figure 3.1b), in which the placenta touches, but does not
overlap, the internal os;
–Lateralplacenta praevia, in which the place nta is inserte d in the lower segment, but more
than 2 cm from the i nternal ce rvical os.
3.1a – Complete 3.1b – Marginal
Figures 3.1
Placenta praevi a
3.1.2 Diagnosis
Signs and symptoms
In a woman more than 5 months pregnant:
– Sudden, bright red bleeding associated with uterine contractions (not always felt by the
patient).
–The foetus often presents high, pushed up by the placenta; the uterus is soft.
– Foetal heart tone usually heard.– Examination with a speculum shows blood flowing from the cervical os.!
!
!
!
!
!
Bleeding during the second half of pre gnancy
453

– Vaginal examination may trigger massive haemorrhage and should be avoided (or should
be done in the operating room, where an emergency caesarean section can be done, if
necessary).
Vaginal examination, if performed, may reveal displacement of the cervix and
deformation of the lowe r uterine segment by the place nta praevia. Rather than the hard
foetal presentation, one feels a spongy mass. If possible, try to determine whether the
placenta covers the enti re cervix, or only part.
Once the di agnosis is e stablished, do not perform another vagi nal examination.
Ultrasound
Ultrasound is the method of choice for di agnosing placenta praevia.
It makes it possible:
–to avoid a vaginal examination;–to determine whether or not the placenta is covering the cervix, and thus the preferred
route of delivery.
3.1.3 Management
– Inse rt an IV line (16-18G catheter) and admi nister Ringer l actate.
–Take pulse and blood pre ssure; assess the severity of the bl eeding.
– Depending on the se verity of bl eeding, prepare for a possi ble transfusi on:
• Determine the pati ent’s blood type;
• Select potenti al donors or verify that blood is avai lable ;
•In the event of a transfer, the woman should be accompanie d by family members who
are potential blood donors;
• If transfusion is necessary, only use blood that has been screened (HIV-1, HIV-2,
hepatitis B, he patitis C and syphi lis).
–If the uterus is scarre d or there is a history of placenta praevia, conside r the possibility of
placenta accreta and prepare to perform a hyste rectomy.
If labour has not yet started and bleeding is minor to moderate
– Re st and monitoring: a sudden, massive haemorrhage is always possible, even if bleeding
has compl etely stopped.
–In cases of complete or parti al placenta praevia:
• The patient should re main hospi talised or cl ose to a CEmONC faci lity.
• Prolong the pregnancy, if possible , up to at least 34 weeks LMP (before 34 week s LMP,
consider foetal lung maturation with dexamethasone, Chapter 4, Se ction 4.10.2).
•Perform a caesarean section:
– between 34 and 37 weeks LMP, despite prematurity, if the situation is unstable
(recurrent bl eeding);
-after 37 weeks LMP after a si ngle episode of bl eeding that has stopped.
If labour has not yet started and bleeding is heavy
–Try a tocol ytic agent to reduce contractions and bl eeding (Chapter 4, Se ction 4.10.2).
–At the same time, prepare for caesarean section (regardless of the placenta's position or
foetal viability), in case the bleeding persists or there is massive, uncontrolled bleeding
(caesarean section to save the l ife of the mother).
– In remote areas, arrange a transfer to a CemONC facility. Be careful of the risk of
exacerbating the bl eeding if transport condi tions are di fficult.Chapter 3
46

If labour has started
– Complete placenta praevia and/or heavy bl eeding: caesarean secti on.
– Placenta praevia not complete and minor bleeding: attempt vaginal delivery; rupture the
membranes as soon as they are accessible, in such a way that the foetal head compresses
the placental vessels and cuts off the bleeding. Be careful of postpartum haemorrhage, which is common with all forms of low-lying
placenta, due to the weaker retraction of the lowe r uterine segme nt. Do not hesitate to
remove the placenta manually and explore the uterine cavity. Administer oxytocin
routinely (Chapte r 8, Section 8.1).Bleeding during the second half of pre gnancy
473

Chapter 3
483.2 Abruptio placentae
Premature separation of the normally implanted placenta, prior to foetal expulsion with
formation of a haematoma between the placenta and the uterine wall. The haematoma
completely or parti ally separates the placenta from the ute rine wall.
Abruptio placentae (or placental abruption) often occurs with trauma or in cases of
hypertension or pre-ecl ampsia.
This can trigger a clotting disorder in the mother, with a risk of severe secondary
haemorrhage (disseminated i ntravascular coagul ation).
Emergency uterine evacuation (vaginal or caesarean) is needed to save the lives of the
mother and foe tus, no matter what the stage of pre gnancy.
3.2.1 Diagnosis
Abruptio placentae is diagnosed clinically. It should be suspected whe n one or more of the
following signs are present:
– Sudden, severe, continuous abdomi nal pain;
– Ute rus in spasm, fee ls hard, “woody”;
– Sudden, light, blackish bleeding; the bleeding may be heavy if there is an associated
clotting disorder;
– Shock, out of proportion to the severity of the external bleeding (intra-uterine bleeding):
rapid or weak or undetectable pulse, very low or undetectable blood pressure;
tachypnoea, pallor, sensation of col d, damp ski n, agitation and anxi ety.
– Foetal hypoxia, depending on the size of the placental abruption: foetal heart rate slows
or foetal heart tone di sappear.
–When the me mbrane s rupture, the fl uid is uniformly red.
Sometime s the picture is incomplete: there may be no vaginal bleeding or uterine spasm, or
no foetal di stress.
Ultrasound, when avai lable , is useful for ve rifying foetal vi tality.
3.2.2 Management (see also al gorithm, following page )
– Inse rt an IV line (16-18G catheter) and admi nister Ringer l actate.
–Take pulse and blood pressure; assess the severity of the bleeding. If there are no clots,
consider the possi bility of a cl otting disorder.
–In remote areas, arrange a transfer to a CEmON C facility, if possible, in anticipation of the
need to transfuse, perform a caesarean section or hysterectomy, and manage postpartum
haemorrhage.
To assess cl otting disorders1:
–Take 2 ml of blood into a dry, clean, glass tube (approximately 10 mm x 75 mm).– Hold the tube in a closed fist to keep it warm (± 37°C).
– After 4 minutes, tip the tube slowly to see if a clot is forming then, tip it again every
minute until the blood clots and the tube can be turned upside down.
– Failure of a clot to form after 7 minutes or a soft clot that breaks down easily suggests
coagulopathy.

Bleeding during the second half of pre gnancy
493For blood transfusi on:
– Determine the pati ent’s blood type.
– Select potenti al donors for possi ble transfusion of fresh whol e blood.
–If transferred, the woman should be accompanied by family membe rs who are potential
blood donors.
–If there is mode rate bleeding and no clotting disorder, transfuse packe d red blood cells or
whole blood.
–If there is massive bleeding and/or a clotting disorder, transfuse fresh whole blood (drawn
less than 4 hours and unrefrigerate d) or packed red blood cells or whole blood combined
with fresh frozen pl asma.
– Blood or other blood products must have been screened (HIV-1, HIV-2, hepatitis B,
hepatitis C and syphi lis).
Delivery should be done quickly, ideally before the onset of clotting disorders. When not
indicated initially, caesarean section becomes imperative if labour progresses too slowly
–even in the event of i ntrauterine foetal death.
Do not prescribe salbutamol to relax the uterine spasm.
Management of abruptio placentae!
Maternal shock
or
diffuse and massive haemorrhage
or
early labour and primipara
or
cervix closedLabour in progre ss
or
Advanced di lation and mul tipara
Emergency
caesare an section Prompt vagi nal delivery:
– amniotomy
– analgesics –± oxytocin to speed up labour–vacuum extractor– manual placenta removal – uterine exploration– uterotonic after placenta removal
Haemodynamic monitoring +++ after
delivery
If bleeding persists: conservative surgi cal treatment
or hysterectomy to stop the bl eeding, if necessary.If caesarean secti on
not feasible

Chapter 3
503.3 Uterine rupture
Tear in the ute rine wall, in most cases during labour.
In a CEmONC or BEmON C facility, uterine rupture can most often be avoide d by monitoring
the progress of labour with partograph, and vi gilant, rational use of oxytoci n.
3.3.1 Circumstances in which uterine rupture occurs
– Afte r prolonged l abour, especially with dystocia in pri miparas.
–Grand mul tiparas (more than 6 de liveries).
–When excessive amounts of uterotonic (oxytocin or mi soprostol) are used.
– Prior history of uterine surgery: caesare an section, especially classical (Figure 3.2); uterine
perforation; myomectomy.
Figure 3.2
Uterine rupture on a cl assical caesarean section scar
3.3.2 Diagnosis
Diagnosis is clinical. A rupture may be diagnosed during labour or after delive ry. Though the
initial symptoms may be subtle – particularly in cases of scarred uterus – the signs are
usually obvious.
During labour
– Impending rupture:
• Maternal agitation;
• Increasingly severe abdominal pain that persists between contractions; abdominal
guarding;
• This picture is often accompanied by a Bandl’s ring (Figures 3.3 and 3.4), a sign of
obstructed labour. At first glance the Bandl ’s ring may look l ike a distended bladder. !

Figure 3.3
Mechanism of Bandl’s ring formationa
Figure 3.4
Impending rupture: hourglass uterus “Bandl's ring”
aAdapted from Primary Surgery Vol.1 – Non-Trauma : The surgery of labour . German Society of Tropical Surgery.
http://www.primary-surgery.org/ps/vol1/html/sect0016.html!
!
!
!
!
Bleeding during the second half of pre gnancy
513

– Rupture:
• Shoulder-tip pain or increased pain on inspiration, a sign of haemoperitoneum.
Sometimes the pain is sudden, during a contraction, and the patient describes a
“tearing” sensation. The pain may be less obvious in cases of posterior uterine rupture.
• Hypovolaemic shock due to bleeding (rapid or weak or unmeasurable pulse, very low or
undetectable blood pressure, tachypnoea, cold sensation, damp skin, agitation oranxiety).
• Contractions stop. • Slow foetal heart rate or no heart tone. • Sometimes feels like foetus can be palpated just below the skin if large, complete
rupture. Foetus is usually dead.
After delivery
A rupture may be discovered during a haemorrhage: uterine exploration after delivery of
the placenta reveals the rupture.
3.3.3 Management (see also al gorithm, following page )
– Inse rt an IV line (16-18G catheter) and admi nister Ringer l actate.
–Take pulse and blood pre ssure; assess the severity of the bl eeding.
– Inse rt a Foley urinary cathe ter.
– Emergency laparotomy with rapid caesarean section, fluid replacement and, in most
case s, blood transfusion.
– Depending on the type of rupture, the patient’ s condition, the time betwee n rupture and
laparotomy and whether there are signs of infection, suture the uterus or perform
hysterectomy.
Keep the surgery as brief as possible, as these patie nts are often in poor general condition
(anaemic, in parti cular).
A sub-umbilical midline incision is preferable (better exposure), sometimes with peri-
umbilical extensi on.
The tear is usually in the lower segment, anterior and low. Enlarge the tear to allow
extraction of the chi ld.
Check the integrity of the bladder, which may have been injure d if it is very adhere nt to the
lower uterine segment (continuous suture in one or two planes and urinary catheterisation
for at least 7 days).
Attempt repair whenever possible. Before suturing the uterine muscle, trim ragged, bruised
edges.Perform a interadnexal subtotal hysterectomy only when there are signs of uterine infection
or extensive rupture with severe brui sing around the wound.
Given the risk of another uterine rupture during subsequent pregnancies, bilateral tubal
ligation may be advised or indicated. This is best discussed before surgery. The patient’s
consent is required. Chapter 3
52

Management of uterine ruptureBleeding during the second half of pre gnancy
533Impending rupture
– labour fails to progress
– agitation, decline in general condition– hypertonic uterus– Bandl’s ring – abdominal pain (more violent than the contractions
and continues between contractions)Rupture
– contractions stop–shock – sometimes, palpation of the
dead foetus expelled intothe mother’s abdominalcavity
Emergency l aparotomy
– extract foetus (usually dead)
– suture the uterus
– discuss tubal ligation if clas –
sical scar and/or mul tipara
– hysterectomy in some cases,
if rupture l arge or infectedPresentation
engagedPresentation
not engaged
Try rapid del ivry
(vacuum extractor)
LaparotomyIf
successfulIf not
successful
Systematic manual expl oration
of the entire uteri ne cavity
for rupture
If
ruptureIf no
rupture
Monitor:risk of haemorrhage due touterine atony or posterioruterine rupture undetected onuterine exploration.

3.4 Diagnosis of bleeding during the second half of
pregnancy (summary)
Table 3.1 – Aetiological diagnosis
Placenta praevia Abruptio placenta Uterine rupture
History
• Twin pregnancy
• Caesarean section• Bleeding during aprevious pregnancy• Pre-eclampsia
• Primipara• Trauma• Long labour
• Primipara
• Dystoci a
• Grand mul tipara (> 6)
• Caesarean secti on
• Overuse of uterotonic
Clinical signs
Bleeding • Bright red bl ood
• Painless bleeding,spontaneous or aftervaginal exam or sexualintercourse• Bleeding without warni ng
sign• Light flow of blackishblood, or sudden bright redbleeding• Bleeding with severe,constant uterine and lowerback painVariable
Haemorrhagicshock • Blood loss vi sible
• Shock proporti onal to
amount of bl eeding• Blood loss not always
visible
• Shock out of proportion to
the amount of visible
bleeding (intra-abdominal or
retroplacental bleeding)
• Diffuse haemorrhage• Blood loss not al ways
visible• Shock out of propor –
tion to the amount ofvisible bleeding (intra-
abdominal bl eeding)
Uterus • Soft uterus • Contractions, if present,are intermittent • Foetus high and mobile • Painful, continuous
contraction (“woody”uterus)• Foetal position hard todetermine (hard uterus andhaematoma)Foetus some times
expelled into theabdominal cavity:uterus is retracted intoa ball, the foetus feltunder the skin
Vaginal exam Soft, spongy placenta
Perform only one, verycautious, vaginal exam ifultrasound is notavailable.Cervix often closed
Vaginal exam not he lpful in
diagnosis of abruptio
placenta.
Foetal hearttone Normal in the absence ofmaternal shock Absent or weak Absent or we akChapter 3
54

References
1World Health Organization. Managing complications in pregnancy and childbirth. A guide
for midwives and doctors. Geneva 2003.
http://whqlibdoc.who.int/publications/2007/9241545879_eng.pdf?ua=1Bleeding during the second half of pre gnancy
553

Chapter 4:
Pathologies during pregnancy andpregnancy-related disorders
4.1 Iron deficiency anaemia ……………………………………………………………………………..59
4.1.1 Diagnosis …………………………………………………………………………………………..59
4.1.2 Treatment ………………………………………………………………………………………….59
4.2 Bacterial infections …………………………………………………………………………………….60
4.2.1 Meningitis …………………………………………………………………………………………60
4.2.2 Typhoid fever ……………………………………………………………………………………..60
4.2.3 Shigellosis ………………………………………………………………………………………….60
4.2.4 Syphilis ………………………………………………………………………………………………61
4.2.5 Gonorrhoea ……………………………………………………………………………………….61
4.2.6 Cystitis and asymptomatic bacteriuria …………………………………………………..61
4.2.7 Pyelonephritis …………………………………………………………………………………….62
4.3 Parasitic infections …………………………………………………………………………………….63
4.3.1 Malaria ……………………………………………………………………………………………..63
4.3.2 Amoebiasis ………………………………………………………………………………………..65
4.3.3 Ascariasis and ancylostomiasis (hookworms) …………………………………………65
4.4 Viral infections …………………………………………………………………………………………..66
4.4.1 Genital herpes ……………………………………………………………………………………66
4.4.2 Varicella (chickenpox) …………………………………………………………………………66
4.4.3 Hepatitis ……………………………………………………………………………………………66
4.4.4 HIV infection ………………………………………………………………………………………67
4.5 Pregnancy-induced hypertension and pre-eclampsia …………………………………….68
4.5.1 Diagnosis of pre-eclampsia ………………………………………………………………….68
4.5.2 Diagnosis of severe pre-eclampsia ………………………………………………………..68
4.5.3 Management of isolated hypertension ………………………………………………….69
4.5.4 Management of mild pre-eclampsia ……………………………………………………..69
4.5.5 Management of severe pre-eclampsia …………………………………………………..70
4.5.6 Secondary prophylaxis for severe pre-eclampsia …………………………………….72
4.6 Eclampsia ………………………………………………………………………………………………….73
4.6.1 Diagnosis …………………………………………………………………………………………..73
4.6.2 Management ……………………………………………………………………………………..73
4.6.3 Secondary prophylaxis …………………………………………………………………………734

4.7 Abnormally large uterus …………………………………………………………………………….74
4.7.1 Diagnosis ………………………………………………………………………………………….74
4.7.2 Management …………………………………………………………………………………….74
4.8 Polyhydramnios ………………………………………………………………………………………..75
4.8.1 Acute polyhydramnios ………………………………………………………………………..75
4.8.2 Chronic polyhydramnios ……………………………………………………………………..75
4.9 Premature rupture of membranes ………………………………………………………………76
4.9.1 Diagnosis ………………………………………………………………………………………….76
4.9.2 Risks …………………………………………………………………………………………………76
4.9.3 Management …………………………………………………………………………………….76
4.10 Threatened preterm delivery ……………………………………………………………………..78
4.10.1 Causative factors ……………………………………………………………………………..78
4.10.2 Management …………………………………………………………………………………..78
4.10.3 Preterm delivery ………………………………………………………………………………79
4.10.4 Preventing preterm delivery ………………………………………………………………79
4.11 Intrauterine foetal death …………………………………………………………………………..80
4.11.1 Diagnosis ………………………………………………………………………………………..80
4.11.2 Management …………………………………………………………………………………..80

4.1 Iron deficiency anaemia
Anaemia is define d as a haemoglobin level below 11 g/dl during the first and third trimester
and below 10.5 g/dl during the second tri mester.
Pregnancy aggravates pre-existing anaemia due, for example, to nutritional deficiency or
malaria.
Anaemia increases the risk of intrauterine growth retardation and preterm birth. It increases
vulnerability in the event of haemorrhage , particularly postpartum hae morrhage .
4.1.1 Diagnosis
– Pallor of the conjunctivae, mucous membranes, palms, and the soles of the feet; fatigue,
dizziness, tachycardi a, heart murmur.
– Signs of se rious illness: intense pallor, lethargy, dyspnoea, hae moglobin be low 7 g/dl.
– Measure haemogl obin level using HemoCue.
4.1.2 Treatment
ferrous sulfate/folic acid (co-formulated tablet containing 200 mg ferrous sulfate equivalent to
65 mg elemental iron + 400 micrograms folic acida) PO: 2 to 3 tablets/day in 2 or 3 divided
doses until haemoglobin level rises to normal, then change to preventive treatment1
(Chapte r 1, Section 1.2.5).
Addition of vitamin C PO (500 mg/day) i mprove s iron absorpti on.
In areas where hookworm is endemic, add a single dose anthelmintic treatme nt as of the
second tri meste r (Chapter 1, Se ction 1.2.5).
In areas where malaria is endemic, add intermittent preventive (Chapte r 1, Section 1.2.5) or
curative (Section 4.3.1) anti malarial treatment, de pending on the mal aria test resul t.
For severe anae mia in the third tri mester:
Arrange for delivery in a CEmONC faci lity.
Ensure active management of third stage of labour and if required, uterine
exploration/manual removal in case of postpartum haemorrhage, or possi ble transfusi on.
Given the risk of haemorrhage and rapid decompensation during delivery, be prepared for
transfusion for any woman whose haemoglobin is below 7 g/dl, even if anaemia is relatively
well-tolerated.
a200 mg ferrous sulfate (65 mg elemental iron) + 400 micrograms folic acid tablets may be replaced by
185 mg ferrous fumarate (60 mg el emental iron) + 400 micrograms fol ic acid tablets. Pathologies during pregnancy and pregnancy-related di sorders
594

Updated: Apri l 2017
4.2 Bacterial infections
For clinical signs and di agnosis, refer to the MSF handbook Clinical guidelines.
Fever above 38.5°C, no matter what its cause, should be treated with paracetamol PO:
3g/day in 3 divided doses.
4.2.1 Meningitis
– Admit to i npatient department; perform lumbar puncture if possi ble.
–Start anti biotic therapy whi le waiting for the re sults:
ceftriaxone IM: 2 g once dai ly
or, if not available:
ampicillin IV: 12 g/day divide d in 3 dose s administere d 8 hours apart, then amoxicillin PO:
6 g/day in 2 or 3 divided doses
Duration of therapy depends on the causative organism (10 to 14 days for S. pneumoniae ;
7 to 10 days for H. influenzae; 5 to 7 days for N. meningitidis; 10 days if the pathogen is
unknown).
– Simultaneously start a short-course of corticosteroids:
dexamethasone IV: 10 mg every 6 hours for 2 days
–In a context of meningococcal meningitis epidemic:
ceftriaxone IM: 2 g once dai ly for 5 days
4.2.2 Typhoid fever
Typhoid fever can cause major complications both for the mother (gastrointestinal
perforation, peritonitis, septicaemia) and the foetus (spontane ous abortion, preterm birth,
intrauterine death).
– Admit to i npatient department.
–In the absence of drug resi stance, amoxicillin PO: 3 g/day in 3 di vide d doses for 14 days
–In cases of drug resistance or severe infection, ceftriaxone IM or IVb: 2 to 4 g once daily for
10 to 14 days
Fever persists 4 to 5 days after starting treatment, even when treatment is effective. It is
essential to treat the fever and to monitor for maternal and foetal complications.
4.2.3 Shigellosis
Admit to i npatient department; ceftriaxone IM: 1 g once dai ly for 3 to 5 days
bThe diluent used to prepare ceftriaxone for IM injection contains lidocaine. Do not administer ceftriaxone
reconstituted with this diluent intravenously. For IV administration, use water for injection only.Chapter 4
60

4.2.4 Syphilis
Syphilis can cause spontaneous abortion, intrauterine death, foetal growth retardation,
preterm bi rth, polyhydramnios, and conge nital syphi lis.
–For the mother:
benzathine benzylpenicillin IMc: 2.4 MIU/i njection (hal f-dose in each buttock)
In early syphilis (less than 2 years): single dose.
In late syphilis (more than 2 years) or if the duration of infection is unknown: oneinjection per week for 3 weeks
2.
Administer the same treatment to the sexual partner(s).
Note: a Jarisch-Herxheimer reaction may occur after the first dose of penicillin, especially in
patients with early syphilis. The patien t presen ts with some of the followin g symptoms:
abrupt onset of fever, chills, muscle pain, tachycardia, flushing, exacerbated skin rash or mild
hypotension, usually within 2 to 5 hours. The treatment is symptomatic (paracetamol PO, 1 g
every 6 hours). The reaction is most often moderate, however severe reactions may occur3.
For penicillin-allergic patients only, erythromycin PO: 2 g/day in 4 divided doses for
14 days. The effectiveness of erythromycin in all stages of syphilis and its ability to
prevent the stigmata of congenital syphilis are both highly questionable, and many
failure s have been reported.
–For the treatment of the ne wborn, see Chapte r 10, Section 10.4.1.
4.2.5 Gonorrhoea
Gonorrhoea can cause premature rupture of membranes, preterm delivery, and severe
neonatal conjunctivitis.
Gonorrhoea is often associated with chlamydial infection.
–For the mother:
Treat simultaneously for gonorrhoea and chlamydia4:
ceftriaxone IM: 250 mg as a si ngle dose
(or, if not available, cefixime PO: 400 mg as a si ngle dose)
+
azithromycin PO: 1 g as a si ngle dose
Give the same treatment to the sexual partner(s).
–For the treatment of the ne wborn, see Chapter 10, Section 10.4.2.
4.2.6 Cystitisand asymptomatic bacteriuria
Cystitis is defined by functional urinary symptoms (frequent, painful urination) and
leukocytes and/or ni trites in urine on di pstick.
Asymptomatic bacteri uria is defined by leukocytes and ni trites in urine on di pstick.
If only leukocytes are detected in urine, repeat the test after vulval toilet with soap and
water.
If still leukocytes only are detected, treat an asymptomatic bacteri uria.
cOnly the intramuscular route may be used. To reduce the pain during the injection, the powder can be
reconstituted with 8 ml of 1% lidocaine (without epinephrine).Pathologies during pregnancy and pregnancy-related di sorders
614

–Increase fl uid intake : at least 1.5 l itres per day.
– Antibiotic therapy for cysti tis or asymptomatic bacteri uria:
fosfomycin-tromethamine PO: 3 g as a si ngle dose
or
cefixime PO: 400 mg/day in 2 di vide d doses for 5 days
or
nitrofurantoin PO (except during the last month of pregnancy): 300 mg/day in 3 divided
dose s for 5 to 7 days
Inform the patient that cystitis symptoms should disappe ar within 2 to 3 days. If not, she
should consult agai n.
4.2.7 Pyelonephritis
– Admit to i npatient department; bed rest (risk of preterm de livery).
–Increase fluid intake: at least 1.5 litres per day.
– Antibiotic therapy:
•In uncomplicated pyelonephritis:
ceftriaxone IM: 1 g once daily for at least 3 days, then cefixime PO: 400 mg/day in
2 divideddoses to complete 14 days of treatment
•In complicated pyelonephritis (e.g. patient in an advanced stage of infection, with sepsis
or in poor clinical condition, vomiting) or treatment failure after 48 hours:
ceftriaxonedIM or slow IV injection (over 3 minute s) or infusion (over 30 minute s): 1 g
once daily then cefixime PO as above
+ gentamicin IM or slow IV (over 3 minute s) or infusion: 3 to 5 mg/kg once daily for the
first 3 days of tre atment
–In the event of ute rine contractions before 37 weeks LMP:
nifedipine or, if not avai lable, salbutamol for 48 hours (Section 4.10)
dThe diluent used to prepare ceftriaxone for IM injection contains lidocaine. Do not administer ceftriaxone
reconstituted with this diluent intravenously. For IV administration, use water for injection only.Chapter 4
62

4.3 Parasitic infections
For clinical signs and diagnosis, refer to the MSF handbook Clinical guidelines.
4.3.1 Malaria5
Malaria in pregnancy is associated with low birth weight, increased anaemia and, in low-
transmission areas, an increased risk of severe malaria and death.
The diagnosis should, if possible, be confirmed by rapid test or microscopic examination
(thick or thin smear).
Uncomplicated falciparum malaria
The treatment of choice is an artemisinin-based combination therapy (ACT) for 3 days.
Table 4.1 – Dosage of ACT
ACT Formulation Dosage
artemether/lumefantrine
(AL or co-artemether)Co-formulated tablets,
20 mg artemether/120 mg
lumefantrine per tab,
blister of 24 tab4 tab twice daily on D1, D2, D3
artemether/lumefantrine(AL or co-artemether) Co-formulated tablets,
80 mg artemether/480 mg
lumefantrine per tab,
blister of 6 tab1 tab twice daily on D1, D2, D3
artesunate (AS)+ sulfadoxine/pyrimethamine (SP)Co-blister containing:
6 tab 100 mg AS
+ 3 tab 500/25 mg SP2 tab AS once daily on D1, D2, D3
+ 3 tab SP as a single dose on D1
artesunate (AS)+ amodiaquine (AQ) Co-formulated tablets,
100 mg AS/270 mg AQ base per tab,
blister of 6 tab2 tab once daily on D1, D2, D3
Co-blister containing:
12 tab 50 mg AS
+ 12 tab 153 mg AQ base4 tab AS + 4 tab AQ once daily on
D1, D2, D3
artesunate/mefloquine
(AS/MQ)Co-formulated tablets,
100 mg AS/220 mg MQ per tab,blister of 6 tab2 tab once daily on D1, D2, D3
dihydroartemisine/
piperaquine
(DHA/PPQ)Coformulated tablets,
40 mg DHA/320 mg PPQ
Blister of 9 tabWomen 36 to < 60 kg
3 tab once daily on D1, D2, D3
Coformulated tablets,
40 mg DHA/320 mg PPQ
Blister of 12 tabWomen 60 to < 80 kg
4 tab once daily on D1, D2, D3Pathologies during pregnancy and pregnancy-related disorders
634Updated: June 2017

Note:
The combination AS/SP is contra-indicated in HIV-infected women taking cotrimoxazole
preventive therapy.
Quinine is an alternative:
quinine PO: 30 mg/kg/day in 3 divided doses for 7 days
Reduced susceptibility to quinine has been observed in South-East Asia and Amazon region.
In these areas, quinine is given in combination with clindamycin PO: 20 mg/kg/day in
2 divided doses for 5 days.
Doxycycline is contra-indicated.
Severe malaria
artesunate slow IV (or, if not feasible, IM into the anterior thigh):
2.4 mg/kg on admission then 12 hours and 24 hours after admission (H0, H12, H24), then
once daily
Note : dilution of the artesunate solution depends on the route of administration (10 mg/ml
for IV route, 20 mg/ml for IM route), refer to the MSF handbook Essential drugs.
or
artemether IM (into the anterior thigh):
3.2 mg/kg on admission then 1.6 mg/kg once daily
As soon as the patient can tolerate oral treatment (but after at least 24 hours of parenteral
treatment), administer a 3-day course of ACT (Table 4.1).
Do not use the combination AS/MQ if the patient developed neurological signs during the
acute phase.
IV quinine (± clindamycin) is an alternative.
quinine IV infusion (dosage is expressed in quinine dihydrochloride):
Loading dose: 20 mg/kg diluted in glucose solution, administered over 4 hours.
Then 5% glucose to keep the vein open over the next 4 hours.
Then maintenance dose: 10 mg/kg over 8 hours, every 8 hours (or, better, alternate 4 hours
of quinine diluted in 5% glucose and 4 hours of 5% glucose).
Do not administer loading dose to patients who have received oral quinine or mefloquine
within the previous 24 hours. In these cases, start with the maintenance dose.
Monitor the patient closely (risk of pulmonary oedema and hypoglycaemia).
As soon as the patient has received at least 3 doses of parenteral quinine and can tolerate
oral treatment, change to quinine PO to complete 7 days of treatment or administer a 3-day
course of ACT (Table 4.1).
If the combination AS/MQ is used as oral completion treatment following IV quinine, start
AS/MQ 12 hours after the last dose of quinine.
Malaria due to P. vivax, P. malariae, P. ovale (irrespective of the age of the pregnancy)
chloroquine PO:
D1, D2: 10 mg base/kg
D3: 5 mg base/kg
Although P. vivax is considered benign, severe cases have been reported. The treatment of
severe malaria should be the same whatever the species.Chapter 4
64Updated: June 2017

4.3.2 Amoebiasis
Pregnant women appear to have an i ncrease d risk of severe disease and death6.
The diagnosis is established by microscopic examination of fresh stools. If the result is
positive:
tinidazole PO: 2 g/day in 2 di vide d doses for 3 days
or metronidazole PO: 1.5 g/day in 3 di vide d doses for 5 days
4.3.3 Ascariasis and ancylostomiasis (hookworms)
For symptomatic i nfection or i nfection proven by fae cal exam:
albendazole PO: 400 mg as a si ngle dose
Do not admi niste r during the first tri mester of pre gnancy.
In the event of ancyl ostomiasis, treat the associated anaemia (Section 4.1).Pathologies during pregnancy and pregnancy-related di sorders
654

4.4 Viral infections
For clinical signs and di agnosis, refer to the MSF handbook Clinical guidelines.
4.4.1 Genital herpes
If the mother has vi sible herpetic l esions at time of chi ldbirth:
– Limit vagi nal exams; no arti ficial rupture of membranes.
– Discuss caesarean se ction on a case-by-case basi s.
–For the mother:
• Pain manage ment: paracetamol PO,1 g 3 times per day
• Antiviral treatment: aciclovirPO, 400 mg 3 times per day for 7 days
In immunocompromised patients, continue the treatment until symptoms resolve.
• Oral aciclovir prophylaxis ( aciclovir PO: 400 mg 4 times per day from 36 weeks LMP and
until delivery) can be proposed to reduce the risk of recurrent herpes at de livery.
–For the treatment of the newborn, see Chapter 10, Section 10.4.3.
4.4.2 Varicella (chickenpox)
There is a risk of severe mate rnal varicella pneumonia and se vere neonatal vari cella.
Aciclovir PO as soon as possible after the onset of rash (800 mg 5 times per day for 7 days)
may reduce these risks7.
4.4.3 Hepatitis
Hepatitis B
Without intervention, mother-to-child transmission of the hepatitis B virus (HBV) is high (up
to 90%).
–For the mother: no speci fic treatment; no spe cial obste tric measure s.
–For the newborn: hepatitis vaccination within hours after birth has been demonstrated to
prevent 70 to 95% of infections. All infants should be vaccinated (Chapter 10, Section 10.1.8)
regardless of the mother’s HBV status. In infants born to HBV-positive mothers, vaccination
AND administration of hepatitis B immune globulin, if available (within 12 hours after birth),
has been demonstrated to prevent 85% to 95% of i nfections8.
Hepatitis E
Hepatitis E carries a very high mortality rate for pregnant women (20% during the third
trimester). It can cause spontaneous abortion, preterm delivery, and intrauterine foetal
death.
The virus is acquired by fecal-oral route (primarily by drinking contaminated water). The
virus can cause outbreaks, especially in situations where large numbers of people are
gathered (refugees, di splaced persons), when hygiene and sani tation are poor.
Management is focused on supportive care (good hydration, avoidance of hepatotoxic
medications). Prevention (water, hygiene, sanitation) is the only protection against the
disease.Chapter 4
66

4.4.4 HIV infection
Mother-to-child HIV transmission may occur at any time during pregnancy, labour, delivery
and the breastfeeding period. With no intervention, the risk of transmission is
approximately 15 to 25% and 20 to 45% if the child is breastfed9. This risk may be reduced
to less than 5%.
Ante-natal care
HIV-infecte d pregnant wome n need antiretroviral therapy regardless of their CD4 count and
clinical stage . The treatme nt should start as soon as possible, regardle ss of gestational age
and should be taken during al l the pregnancy.
Intra-partum care
–Offer voluntary counse lling and te sting on admi ssion if HIV status is unk nown.
– Adminis ter antiretro viral therap y at onset of labou r and durin g delivery, as indicated in
specialized Pre vention of Mother-To-Chi ld Transmi ssion (PMTCT) gui delines.
–Observe standard pre cautions to avoid contact with blood and body fl uids.
– Avoid:
• prolonge d labour;
• prolonge d rupture of membranes;
• early arti ficial rupture of me mbranes;
• invasive procedure s such as episiotomy or instrumental delivery. However, they must
be performed if they are necessary for de livering the chi ld.
– The criteria for i nduction of labour are the same as for non HIV-i nfecte d women.
– Clamp umbi lical cord i mmediately.
– Administe r antiretroviral prophyl axis to the newborn i mmediately after bi rth.
– Prevention and treatment of postpartum haemorrhage: as for non HIV-infecte d women.
However ergometrine or methylergometrine should not be used in women taking
antiretrovirals unless alternative treatments (oxytocin or misoprostol) are not available. In
this case and if the need for pharmacologic treatment outweighs the risks, ergometrine/
methylergometrine should be used in low a dosage and the duration of treatme nt should
be as short as possi ble.
A planned caesarean section can be beneficial if the viral load is detectable . However, given
the risks associated with the intervention (surgical, anaesthetic and infectious) and the risk
of uterine rupture during subse quent pregnancies, caesarean section is not recommended
routinely.
Post-partum care
–Offer voluntary counsel ling and testing if HIV status has not been determined before.
– Continuation of antiretrovira l therap y for the moth er, at least durin g breast-feedin g, or
for life, depending on the si tuation.
– For the newborn: antiretroviral prophylaxis to the newborn as indicated in PMTCT
guidelines.Pathologies during pregnancy and pregnancy-related di sorders
674

4.5 Pregnancy-induced hypertension and pre-eclampsia
Normally, blood pressure (BP) slightly decreases during pregnancy. In a pregnant woman,
hypertension is defined as BP ≥ 140/90 mmHg. To confirm hypertension, check BP several
times, with the woman seated and at rest.
Chronic hypertension is defined as hypertension predating the pregnancy or appearing
before 20 weeks LMP.
Pregnancy-induced hypertension (PIH) is defined as isolated hypertension, without
proteinuria, that appears after 20 weeks LMP.
Pre-eclampsia refers to pregnancy-induced hypertension accompanied by proteinuria. Pre-
eclampsia carries a significant risk of foetal growth retardation, foetal distress, foetal death,
placental abruption and ecl ampsia.
High BP is the most visible sign of pre-eclampsia. However, pre-eclampsia is a complex
disease affecting mul tiple organs, i ncluding l iver and ki dneys.
The goal of antihypertensive treatment is to prevent the maternal complications of severe
hypertension. Treatment is administered if systolic BP is ≥ 160 mmHg or if diastolic BP is
≥ 110 mmHg. The objective is to lower BP to about 140/90 mmHg. Antihypertensive
treatment does not improve the foetal prognosi s.
Hypertensive treatment in pregnant women should be carried out with caution. It is
essential to preserve pl acental perfusion and to avoid e xcessive fal l in maternal BP.
4.5.1 Diagnosis of pre-eclampsia
–BP ≥ 140/90 mmHg AND prote inuria (1+ or more on di pstick test).
– Othe r signs may be prese nt: dark urine, low urine output, and oede mas (legs, hands) that
appe ar suddenly or worsen rapi dly.
Note: in women with proteinuria and no hypertension, consider urinary tract infection,
contamination of urine with blood or vaginal secretions, genito-urinary schistosomiasis in
endemic areas, or renal disease. In these cases, monitor continuously, to ensure early
detection of pre-ecl ampsia.
4.5.2 Diagnosis of severe pre-eclampsia
– Systolic BP ≥ 160 mmHg or diastolic BP ≥ 110 mmHg, persistently elevated in spite of
treatment.
– Proteinuria (3+ or more on di pstick test or more than 5 g/day).
– Oliguria (urine output < 400 ml/day or < 30 ml /hour).
– Hyperreflexia (overactive knee-jerk response, twi tching and spasms).
– Epigastric pai n, nausea, vomi ting.
– Facial oedema, pulmonary oedema.
–Intense headaches not rel ieved by paracetamol .
– Buzzing in the ears, vi sual disturbances.
When feasib le, measu re platelets and liver enzymes to assess the severit y of the disease.
The  HELLP syndrome (haemolysis, elevated liver enzymes, low platelets) is a potential life-
threatening compl ication for both the mother and foetus).Chapter 4
68

4.5.3 Management of isolated hypertension
–Rest and moni toring: BP, weight; look for oedema and protei nuria.
– Measure the fundal he ight (risk of foe tal growth retardati on).
– Normal sodium and cal oric intake.
–In the event of protei nuria devel oping, treat as for pre -eclampsia.
– If systolic BP is ≥ 160 mmHg or diastolic BP is ≥ 110 mmHg, give an antihypertensive
treatment:
labetalol PO: 200 mg/day in 2 divided doses then increase if necessary, in 100 to 200 mg
increments until an effective dose is reached, usually 400 to 800 mg/day in 2 divided
dose s. If higher doses are re quired, give in 3 di vided doses. Do not exceed 2.4 g/day.
If the mother is taking labetalol, monitor the newborn for at least 72 hours after birth
(risk of hypogl ycaemia, bradycardia and respiratory di stress).
or
methyldopa PO: 500 to 750 mg/day in 2 or 3 divided doses for 2 days, then increase if
necessary, in 250 mg increments every 2 to 3 days, until an effective dose is reached,
usually around 1.5 g/day. Do not e xceed 3 g/day.
In case of treatment failure, these drugs can be associated. Do not stop treatment
abruptly.
Diuretics and angiotensin-converting-enzyme inhibitors (captopril, enalapril, etc.) are
contra-indicated.
4.5.4 Management of mild pre-eclampsia
Before 37 weeks LMP
–Rest and moni toring: BP, wei ght, oedema, proteinuria at least once a wee k.
– Measure the fundal he ight (risk of foe tal growth retardati on).
– Normal sodium and cal oric intake.
–Do not stop uterine contractions if they occur; l et the woman del iver.
– If systolic BP is ≥ 160 mmHg or diastolic BP is ≥ 110 mmHg: labetalol or methyldopa
(Section 4.5.3).
Pre-eclampsia is an evolving condition, always deteriorating. As soon as even a single sign of
severe pre-ecl ampsia appears, transfer to a CEmONC faci lity.
After 37 weeks LMP
–Same moni toring and anti hypertensive treatment.
– If there is true intrauterine growth retardation, induce labour for vaginal delivery, or
perform a caesarean secti on.
–If there is no growth retardation, continue to monitor and induce labour as soon as the
cervix is favourabl e.Pathologies during pregnancy and pregnancy-related di sorders
694

4.5.5 Management of severe pre-eclampsia
Care is best organized with a multi-disciplinary team comprising obstetrician,
anaesthesiologist and mi dwife.
Delivery
Delivery is imperative within 24 hours, eithe r vaginally or by caesare an section, depending
on the state of the cervix, gestati onal age and condi tion of the foe tus.
Magnesium sulfate treatment
To reduce the risk of eclampsia, administer magnesium sulfate (MgSO4). One of the
following re gimens may be use d:
• Verify the dosage written on the MgSO4 ampoules (there are di ffere nt dosage s).
• There is a risk of potentially lethal overdose of MgSO4. Have calcium gluconate,
the antidote of MgSO4, i mmediately avai lable (1 g ampoul e).
During admi nistration, monitor:
– Patellar reflex (knee-jerk), BP, pulse and respiratory rate every 15 minutes for the first
hour of treatment. If there are no signs of overdose , continue moni toring every hour.
– Urine output every hour (insert Foley catheter).
Manifestations of MgSO4 overdose start with disappearance of the patellar reflex then
hypotension, arrhythmia, respiratory depression (< 12 breaths/minute). If the patellar reflex
disappears, stop MgSO4 i mmediately and admi nister calcium gluconate (1 g IV).
If urine output drops (< 30 ml/hour or 100 ml/4 hours): stop MgSO4 and deliver as quickly as
possible.
Antihypertensive treatment
If systolic BP is ≥ 160 mmHg or diastolic BP is ≥ 110 mmHg: labetalol or methyldopa
(Section 4.5.3).If the oral route is impossible, use injectable labetalol or hydralazine. When administering,
monitor the mother’s BP and pulse and the foetal heart rate.MgSO4
5 g ampoul e
(500 mg/ml , 10 ml)
IV/IM protocolLoading dose: 4 g by IV infusion in 100 ml of 0.9% sodium chloride
over 15 to 20 minutes.
Then
Maintenance dose : 10 g IM (5 g in each buttock), followe d by 5 g IM
every 4 hours (change sides with each i njection).
Continue this treatment for 24 hours after del ivery.
or
MgSO4
5 g ampoul e
(500 mg/ml , 10 ml)
IV protocolLoading dose: 4 g by IV infusion in 100 ml of 0.9% sodium chloride
over 15 to 20 minutes.
Then Maintenance dose: 1 g/hour by continuous i nfusion.
Continue this treatment for 24 hours after del ivery.
!
Chapter 4
70

The dose is adjuste d according to changes in BP. Hypertension is controlled when diastolic
BP is between 90 and 100 mmHg and systol ic BP between 130 and 150 mmHg.
Respect dosage and administration rate. Administering too much of the drug, or
administering it too quickly, can provoke a sudden, excessive fall in maternal BP, with
placental hypoperfusion and foetal death. Diastolic BP should not go below 90 mmHg. In
the event of hypotension, use Ringer lactate solution to bring the diastolic BP back up to
≥90 mmHg.
One of the fol lowing re gime ns may be use d:
Notes:
– If the mother receives labetalol, monitor the newborn for at least 72 hours after birth
(risk of hypogl ycaemia, bradycardia and respiratory distress).
–If anaesthesia is necessary, avoid ketamine. Whenever possi ble, use spinal anaesthesi a.
– Oxytocin may be used in pre-eclampsia, but requires BP monitoring: drops and elevations
in BP have been described in rare cases.
– Ergometrine and methyl ergometrine are contrai ndicated.
– Pre-eclampsia can appear up to 48 hours after del ivery, and on rare occasions even l ater.!
labetalol
slow IV
(ampoule of100 mg in 20 ml,5 mg/ml)One dose of 20 mg (4 ml) over at least one minute. Check BP 5 and
10 minutes after injection. If hypertension remains uncontrolled,
administe r another dose of 20 mg and check BP. Administe r additional
doses, of 40 mg then 80 mg with 10 minute s betwee n each dose as long
as hypertension is not controlle d. Do not excee d a cumulative dose of
300 mg.
or
hydralazine
slow IV (20 mg/1 ml vial)Dilute 20 mg (1 vial of hydralazine reconstituted in 1 ml of water for
injection) in 9 ml of 0.9% sodiu m chlorid e to obtain 10 ml of solution
containing 2 mg hydral azine/ml.
Administer 5 mg (2.5 ml of the diluted solution) over 2 to 4 minutes.
Monitor BP for 20 minutes. If hypertension remains uncontrolled,
repeat injection. Continue repeating if necessary, waiting 20 minutes
between each i njection. Do not e xceed a cumul ative dose of 20 mg.
or
hydralazine IV
infusion (20 mg/1 ml vial)Dilute 100 mg (5 vials of reconstituted hydralazin e) in 500 ml of 0.9%
sodium chloride or Ringer lactate to obtain a 200 micrograms/ml
solution.The initial dose is 200 to 300 micrograms/minute; the maintenance
dose is 50 to 150 mi crograms/minute.
Administer by increasing the rate up to 20 drops/minute (maximum
30 drops/minute), monitoring the BP every 5 mi nutes.
As soon as the hypertension is controlled, gradually reduce the rate
(15 drops/minute, then 10, then 5) until stopping infusion. Stopping
abruptly can trigger a hypertensive cri sis.Pathologies during pregnancy and pregnancy-related di sorders
714

4.5.6 Secondary prophylaxis for severe pre-eclampsia
Acetylsalicylic acid PO: 75 mg/day starting at 12 weeks LMP and continuing until 36 weeks
LMP reduces the risk of recurrence during the next pregnancy. If this prophylactic treatment
is feasible, recommend that the woman comes for consultation as soon as she knows she is
pregnant. There is no point in starting this treatment after 20 weeks LMP10.
During the next pregnancy, calcium supplementation is recommended11in women with low
calcium intake (see Chapter 1, Section 1.2.5).Chapter 4
72

4.6 Eclampsia
4.6.1 Diagnosis
Convulsions during the third trimester of pregnancy, most commonly in a context of pre-
eclampsia. Ecl ampsia can also occur wi thin 48 hours after de livery.
Consider other causes of convulsions, such as meningitis and cerebral malaria (their
incidence is i ncrease d in pregnant women).
4.6.2 Management
–Protect against i njury, maintain airway, place in recovery posi tion.
– Seizures: magnesium sulfateeas for severe pre-eclampsia (Section 4.5.5). Continue treatment
for 24 hours after delivery or 24 hours after the last seizure, whichever was more recent.
– Nursing care, hydration, urinary catheter insertion; monitoring as for severe pre-eclampsia
(Section 4.5.5).
– Oxygen: 4 to 6 litres/minute.
– If systolic BP is ≥ 160 mmHg or diastolic BP is ≥ 110 mmHg: antihypertensive treatment as for
severe pre-eclampsia (Section 4.5.5).
– Delivery imperative within 12 hours, either vaginally or by caesarean section, depending on
the state of the cervix, gestational age and the condition of the foetus.
4.6.3 Secondary prophylaxis
Acetylsalicylic acid PO, as for pre-ecl ampsia (Section 4.5.6).
eIf magnesium sulfate is not available, use diazepam : 10 mg by slow IV (or by rectal route), then 40 mg in a
500 ml of 5% glucose admi nistered over 24 hours. Venti lation equipment must be i mmediately avai lable.Pathologies during pregnancy and pregnancy-related di sorders
734

4.7 Abnormally large uterus
4.7.1 Diagnosis
Fundal height greater than the presumed gestati onal age.
The possible causes are:
– Incorrect due date;– Multiple pregnancy, polyhydramnios, molar pregnancy;–A large-for-gestational-age foetus (macrosomia).
4.7.2 Management
– Verify the due date (date of last menstrual peri od).
–Perform ultrasound, if possible.
– Twin pregnancy (Chapter 6, Section 6.2), polyhydramnios (Section 4.8), molar pregnancy
(Chapter 2, Section 2.3).
– Macrosomia:
Access to CEmoNC facilities need to be ensured due to the increased risk of foeto-pelvic
disproportion and need for caesarean section. If referral of the patient durin g labou r is
likely to be di fficult (distance, security), refer patient prior to onset of labour if fe asible.
The risk of post-partum haemorrhage is increased: routi nely insert an IV l ine.
Other risks associated with macrosomia include dynamic dystocia, prolonged labour,
shoulder dystocia and pe rineal tear at del ivery.Chapter 4
74

4.8 Polyhydramnios
Excess amniotic fluid (more than 2 litres at term), commonly due to foetal anomalie s. There
are two cl inical situations:
–In the second tri mester: acute pol yhydramnios;
–In the third tri mester: chronic pol yhydramnios.
4.8.1 Acute polyhydramnios (rare but serious)
Diagnosis
– Rapid i ncre ase in the si ze of the uterus
– Painful abdomen, abdomi nal pressure, dyspnoea
– Distended, hard uterus, foetus cannot be pal pated
Usually associated with foetal malformation, sometimes a complicated twin pregnancy.
Management
Do not intervene ; let the pati ent abort or de liver spontaneousl y.
4.8.2 Chronic polyhydramnios
Diagnosis
–More moderate i ncrease in the size of the uterus, occurring in spurts
–Foetus cannot be pal pated
– Receding head on vagi nal exami nation, fluid wave
– Foetal heartbeat muffl ed
Management
– Monitor.
–Look for diabetes and treat if found.– Examine the newborn for malformation.– Risk of neonatal hypoglycaemia: Chapter 10, Section 10.3.4.
Notes:
In acute and chronic polyhydramnios:–Do not puncture or drain amniotic fluid during pregnancy: risk of infection.– Use of oxytocin during labour is dangerous and oxytocin should be administered with
caution as the over-distended uterus may rupture.
– Amniotomy carries risk of cord prolapse: taking into account gestational age and potential
presence of fœtal malformation, a caesarean section may be considered. In the event ofacute polyhydramnios in the second trimester, vaginal delivery should be pursued.
– Risk of post-partum haemorrhage (insert routinely an IV line).Pathologies during pregnancy and pregnancy-related di sorders
754

4.9 Premature rupture of membranes
4.9.1 Diagnosis
Discharge of amniotic fluid before the onset of labour, due to a leak or frank rupture of the
amniotic sac.
Differential diagnosis: urinary incontinence, expulsion of the mucus plug, leucorrhoea.
4.9.2 Risks
– Intra-amniotic infection; suspect infection if there is maternal fever, persistent foetal
tachycardia or loss of foe tal heartbeat, or discoloure d amniotic fluid.
Never administer a tocolytic agent, no matter what the gestational age, when intra-
amniotic i nfection is suspected.
–Pre-term bi rth, if the rupture occurs before 37 weeks LMP.
4.9.3 Management
–For confirmation in case of doubt, perform speculum examination: look for fluid pooling
in the vagina or l eaking from cervi cal os when pati ent coughs.
–Look for a prolapsed cord (Chapter 5, Section 5.4).
–Look for a mate rnal cause (e.g. urinary tract or vagi nal infection) and treat accordi ngly.
– Admit to inpatient department; rest and monitoring: temperature, heart rate, blood
pressure, uterine contractions, foetal heart tone, and abnormal amniotic fluid (discoloured,
purulent).
– Vaginal examinations: as few as possible, always with sterile gloves and only if the woman
is in labour or i nduction of labour is pl anned.
– Antibiotic therapy:
•For the mother (routi nely)
No infection, no labour, and rupture ≥ 12 hours:
amoxicillin POf: 3 g/day in 3 di vided doses for 5 to 7 days
No infection, labour in progress, and rupture ≥ 12 hours:
ampicillin IV: initially 2 g, then 1 g every 4 hours during labour until the child is born,
whether the patient received antibiotics beforehand or not; do not continue antibiotics
postpartum.
If infection is present, with or without labour, regardless of the duration of the rupture:
ampicillin IV: 2 g every 6 hours + metronidazole IV: 500 mg every 8 hours + gentamicin IM:
3 to 5 mg/kg once daily
Continue IV administration for 48 hours after fever disappears then, change toamoxicillin + metronidazole PO to complete 10 days of treatment.
•For the newborn: see Chapter 10, Sections 10.3.3 and 10.3.4.
fDo not use amoxicillin/clavulanic acid (increased incidence of necrotizing enterocolitis in neonates).Chapter 4
76

–If there are ute rine contracti ons:
•Before 34 weeks LMP: tocol ytic agent, except if there are signs of amni otic infection.
•After 34 weeks LMP, the risk of infection is greate r than the risk of preterm birth: do
not administer tocol ytics.
– Induction of l abour:
•In case of i nfection, induce labour i mmediately (Chapter 7, Se ction 7.3).
•If there is no infection, conside r induction as of 34 wee ks LMP if the due date is certain,
bette r as of 37 weeks LMP.
–For rupture s occurring in the seve nth and eighth month, transfer the mother, if possible,
to a facility where the preterm infant can receive i ntensive care .
–Prepare the foetus for preterm bi rth:
After 26 wee ks LMP and before 34 weeks LMP, help lung maturation with dexamethasone
IM: 6 mg every 12hours for 48 hours. In case of severe maternal infection, start antibiotic
therapy prior to de xamethasone.Pathologies during pregnancy and pregnancy-related di sorders
774

4.10 Threatened preterm delivery
Regular ute rine contractions and ce rvical changes before 37 weeks LMP.
4.10.1 Causative factors
–Premature rupture of me mbranes
– Infection, fever
– Pregnancy-related disorder: pre-eclampsia, polyhydramnios, placenta praevia– Malnutrition– Multiple pregnancy– Cervical incompetence, immature uterus in the young primipara
4.10.2 Management
– Always look for malaria (rapid test) and urinary tract infection (dipstick test); treat the
apparent cause s.
–Let the woman de liver:
•If she is > 34 weeks LMP and her waters have broken.
•If labour is too advanced to be stopped (cervix effaced, 4 cm dilation), no matte r what
gestational age.
• If the mother’s life is threatened (very poor general condition, pre-eclampsia,
eclampsia, abruptio pl acentae, etc.), no matter what gestati onal age.
•If foetal death is confirmed (no foetal moveme nts and no foetal heart tone at several
checks or ultrasound confi rmation of foetal death).
– Otherwise, try to stop the contracti ons:
• Strict bed rest in a medical setting. Bed rest alone is enough in mild forms (contractions
without cervi cal changes).
• Tocolytic the rapy:
The main objective is to postpone delivery in order to administer corticosteroids for
accelerating foe tal lung maturati on:
nifedipine PO
(short-acting
capsule 10 mg)10 mg to be repeated every 15 minutes if uterine contractions persist
(maximum 4 doses or 40 mg), then 20 mg every 6 hours Never administer sublingually (risk of placental hypoperfusion and foetal
death); always use the oral route.
or, if not avai lable
salbutamol
IV infusion
(0.5 mg ampoule)Salbutamol has numerous contra-indications (see the MSF handbook Essential
Drugs).
Dilute 5 mg (ten 0.5 mg ampoules) in 500 ml of 5% glucose or 0.9% sodium
chloride, to obtain a 10 mi crograms/ml sol ution.
Start at a rate of 15 to 20 mi crograms/minute (30 to 40 drops /minute).
If contractions persist, increase the rate by 10 to 20 drops/minute every
30 minutes until contractions stop. Do not exceed 45 micrograms/minute
(90 drops/minute).
Maintain the effective rate for one hour after contractions stop then, reduce
the rate by half every 6 hours. Monitor the mother’ s heart rate regularly, and reduce the rate in the event of
maternal tachycardia (> 120 beats/minute). Chapter 4
78

Duration of the treatment is 48 hours, regardl ess of which drug is use d.
Do not combine nifedipine and salbutamol.
Salbutamol IV administration requires the constant presence of qualified personnel
capable of appropriate medical supervision. If the infusion cannot be properly monitored,
administe r the salbutamol by IM route: 0.5 mg every 6 hours for 48 hours.
–Prepare the foetus for preterm birth:
After 26 weeks LMP and before 34 weeks LMP, help lung maturation with dexamethasone
IM: 6 mg every 12hours for 48 hours. In case of severe maternal infection, start antibiotic
therapy prior to de xamethasone.
4.10.3 Preterm delivery
– Delivery is usual ly rapid and often breech.
– Avoid aggressive treatment (drugs or procedures), but above all, avoid a long labour.
Expulsion should be rapid: possible episiotomy, even if the child is small; vacuum
extraction is contra-indicated—if possible, use forceps if instrumental extraction is
required.
– Provide for a good warming control (kangourou mother care, cap) and newborn
resuscitation. Monitor temperature (risk of hypothermia) and blood glucose (risk of
hypoglycaemia).
4.10.4 Preventing preterm delivery
– Treatme nt of infections and other di sorde rs during pregnancy.
– Bed rest for women with predisposing factors: multiple pregnancy, polyhydramnios,
previous preterm de livery, tired grand mul tipara.Pathologies during pregnancy and pregnancy-related di sorders
794

4.11 Intrauterine foetal death
Foetal death during the second or third tri meste r of pregnancy, prior to l abour.
4.11.1 Diagnosis
–Absence or ce ssation of foetal movements—the usual reason for consul tation.
– Fundal height too smal l for gestati onal age, or de crease in fundal he ight from a prior vi sit.
–Absence of foetal heart tone.
– Sometimes, breast engorgement indicating the end of the pregnancy.
None of these signs is sufficiently sensitive to justify a hasty, rash decision. Errors are
common. Repeat the exam, do not rush. Diagnosis can be confirmed by ultrasound.
4.11.2 Management
–If the mother has no l ife-threatening di sorder:
•Treat any maternal disorders (anaemi a, malaria, etc.).
•If it is certain that the foetus is dead, i nduce labour.
•If there is any uncertainty, see the woman again at regular intervals (e.g., once a week)
and wait for labour to start spontaneously; this generally occurs within 15 to 20 days of
foetal death.
–If the mother has a l ife-threatening di sorder:
Urgent ly indu ce labou r in the event of eclampsia , placenta praevia , abruptio placentae,
intra-amniotic i nfection, severe maternal di sease (e.g., congesti ve heart failure).
– If the amniotic sac has been ruptured for more than 12 hours: antibiotic therapy
(Section 4.9.3) and i nduction of l abour.
– Induction of l abour:
• In the third trimester, if the cervix is favourable: administer oxytocin and rupture
membranes.
•If the cervix is not favourabl e or in the second tri mester:
Administer the combi nation mi fepristone if avai lable + a prostagl andin:
mifepristone PO: 600 mg once daily for 2 days followed on the third day by a
prostaglandin (see doses bel ow).
or a prostagl andin alone:
misoprostol intravaginally into the posterior fornix, every 6 hours, until labour begins
(max. 3 doses within 24 hours, to be repeated on the following day if required):
200 micrograms in the second trimester or 100 micrograms in the third trimester or
50 micrograms in the ninth month.
or dinoprostone gel (1 mg in 3 g of gel): 1 mg intravaginally into the posterior fornix
every 6 hours, maximum 3 wi thin 24 hours.Chapter 4
80

•In case of prior caesarean section or grand multiparity, given incre ased risk of uterine
rupture:
The combination mifepristone + prostaglandin should be favoured to reduce the
numbe r prostagl andin doses re quired.
Reduce by half the doses of oxytocin or mi soprostol.
Do not gi ve more than 3 doses of mi soprostol or di noprostone.
– During labour, in cases of malpresentation or foetopelvic disproportion: try everything
possible to avoid a caesarean section; accept a long labour, and perform destructive
delivery. Caesarean se ction should only be pe rforme d as a last resort.
Caesarean section is performed right away only in cases of complete placenta praevia
and/or hae morrhage, where the re is a risk of maternal death or uterine rupture.
– Carefully examine the placenta (possi bility of re taine d fragments).
– Perform a manual exploration of the uterus if there is retained placenta or any sign of
bleeding (coagulation disorders). Give routine antibiotic prophylaxis (cefazolin or
ampicillin slow IVg, 2 g as a si ngle dose).
–After delivery:
Mothers are at risk of psychological problems after a stillbirth; perinatal death is
associate d with increased rates of postpartum depressi on.
Psychological support should be offered to all women at the maternity hospital and in
post-partum peri od.
Inhibition of lactation is of psychological importance for some women following intra
uterine death (see Chapter 11, Section 11.2.1).Staff should avoid persuading parents to see and hold the infant but should strongly
support such desire s whe n expressed (however, this is discouraged if the infant has been
mutilated in case of embryotomy or presents severe malformations). In this case, prepare
the infant as usual, cleaned, wrapped. The body must be given to parents if they want to
organize a funeral .
gFor patients with a history of immediate hypersensitivity reaction to penicillin (urticaria, respiratory
problems or oedema): clindamycin IV, 900 mg as a si ngle dose.Pathologies during pregnancy and pregnancy-related di sorders
814

References
1World Health Organization. Guideline: Daily iron and folic acid supplementation in
pregnant women. Geneva. 2012.
http://apps.who.int/iris/bitstream/10665/77770/1/9789241501996_eng.pdf
2Guidelines for the management of sexually transmitted infections. World Health
Organization, Geneva, 2003.
http://apps.who.int/iris/bitstream/10665/42782/1/9241546263_eng.pdf
3Yang CJ, Lee NY, Lin YH, et al. Jarisch-Herxheimer reaction after penicillin therapy among
patients with syphilis in the era of the HIV infection epidemic: incidence and risk factors.
Clin Infect Dis. 2010 Oct 15;51(8):976-9. doi: 10.1086/656419.
http://cid.oxfordjournals.org/content/51/8/976.full.pdfhttp://cid.oxfordjournals.org/content/51/8/976.full.pdf
4Update to CDC's Sexually Transmitted Diseases Treatment Guidelines, Infections Weekly
August 10, 2012 / 61(31);590-594.
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6131a3.htm?s_cid=mm6131a3_w
5Guidelines for the treatment of malaria. Second edition. World Health Organization,
Geneva, 2010.
http://whqlibdoc.who.int/publications/2010/9789241547925_eng.pdf
6Antiamoebic drugs for treating amoebic colitis (Review). The Cochrane Collaboration, 2009.
Published by John Wiley & Sons, Ltd.
http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD006085.pub2/pdf
7Clinical practice guideline of the Society of Obstetricians and Gynaecologists of Canada.
Management of Varicella Infection (Chickenpox) in Pregnancy, No. 274, March 2012.
http://sogc.org/wp-content/uploads/2013/01/gui274CPG1203E.pdf?1668a1
8Hepatitis B. Epidemiology and Prevention of Vaccine-Preventable Diseases. The Pink Book:
Course Textbook – 12thEdition Second Printing (May 2012).
http://www.cdc.gov/vaccines/pubs/pinkbook/hepb.html#hepA
9HIV transmission through breastfeeding. A review of available evidence. World Health
Organization, UNFPA. Geneva, 2004.
http://www.unfpa.org/webdav/site/global/shared/documents/publications/2004/hiv_transmission.pdf
10Prevention and treatment of pre-eclampsia and eclampsia. Summary of recommendations.
World Health Organization. Geneva, 2011. WHO/RHR/11.30.
http://www.who.int/reproductivehealth/publications/maternal_perinatal_health/rhr_11_30/en/
11Calcium supplementation in pregnant women. World Health Organization. 2013.
http://apps.who.int/iris/bitstream/10665/85120/1/9789241505376_eng.pdfChapter 4
82

5Chapter 5:
Normal delivery and procedures related tovaginal delivery
5.1 Normal delivery …………………………………………………………………………………………85
5.1.1 General recommendations …………………………………………………………………..85
5.1.2 Diagnosing the start of labour ……………………………………………………………..85
5.1.3 Stages of labour …………………………………………………………………………………85
5.1.4 First stage: dilation and descent of the foetus ………………………………………..86
5.1.5 Second stage: delivery of the foetus ………………………………………………………89
5.1.6 Oxytocin administration ………………………………………………………………………92
5.1.7 Umbilical cord clamping ………………………………………………………………………92
5.2 Monitoring labour and delivery …………………………………………………………………..93
5.2.1 Partograph ………………………………………………………………………………………..93
5.2.2 Postpartum maternal monitoring in the delivery room ……………………………95
5.3 Artificial rupture of the membranes (amniotomy) ………………………………………..96
5.3.1 Indications …………………………………………………………………………………………96
5.3.2 Precautions ………………………………………………………………………………………..96
5.3.3 Contra-indications ………………………………………………………………………………96
5.3.4 Technique ………………………………………………………………………………………….96
5.4 Prolapsed cord …………………………………………………………………………………………..98
5.4.1 Diagnosis …………………………………………………………………………………………..98
5.4.2 Management ……………………………………………………………………………………..99
5.5 Nuchal cord ……………………………………………………………………………………………..100
5.6 Instrumental delivery ……………………………………………………………………………….101
5.6.1 Vacuum extractor ……………………………………………………………………………..101
5.6.2 Forceps ……………………………………………………………………………………………104
5.7 Symphysiotomy ……………………………………………………………………………………….105
5.7.1 Indications ……………………………………………………………………………………….105
5.7.2 Conditions………………………………………………………………………………………..105
5.7.3 Contra-indications …………………………………………………………………………….105
5.7.4 Equipment ……………………………………………………………………………………….106
5.7.5 Technique ………………………………………………………………………………………..106
5.7.6 Post-operative care …………………………………………………………………………..108
5.7.7 Complications …………………………………………………………………………………..108

5.8 Episiotomy ……………………………………………………………………………………………..109
5.8.1 Indications ………………………………………………………………………………………109
5.8.2 Equipment ………………………………………………………………………………………109
5.8.3 Technique ……………………………………………………………………………………….109
5.9 Perineal repair ………………………………………………………………………………………..111
5.9.1 Equipment ………………………………………………………………………………………111
5.9.2 Technique ……………………………………………………………………………………….112
5.9.3 Post-operative care ………………………………………………………………………….113
5.9.4 Management of complications ………………………………………………………….114
5.10 Deinfibulation …………………………………………………………………………………………115
5.10.1 Equipment …………………………………………………………………………………….115
5.10.2 Technique ……………………………………………………………………………………..115

5.1 Normal delivery
5.1.1 General recommendations
During delivery, the risk of HIV transmission to personnel necessitates the wearing of gloves,
mask, protective eyewear and gown for all procedures, no matter how simple—including
normal del iveries, mothers who are not considered a ri sk, and emergencies.
Ensure a calm reassuring environme nt and provide the woman as much privacy as possible
during examinations and delivery. Encourage her to be accompanied by a person of her
choice.
5.1.2 Diagnosing the start of labour
– Onset of uterine contractions: intermittent, rhythmic pains accompanied by a hardening of
the uterus, progressively increasing in strength and frequency;
And
– Cervical changes: progressive shortening (effacement) and dilation(Figure 5.1):
•In a primipara, the cervix wi ll first efface the n, dilate;
•In a multipara, efface ment and dilatation occur si multaneously.
Repeated contractions without cervical changes should not be considered as the start of
labour. Repeated contractions that are ineffective (unaccompanie d by cervical changes) and
irregular, which spontaneously stop and then possibly start up again, represent false labour.
In this case, do not rupture the me mbranes, do not admi niste r oxytocin.
5.1.3 Stages of labour
First stage: dilation and foetal descent, divided into 2 phases
1) Latent phase: from the start of labour to 4 cm of dilation. Its duration varies depending
on the number of prior deliveries.
2) Active phase: from 4 cm to complete dilation. The cervix dilates at an average of one cm
per hour. The time to dilate varies with the number of previous deliveries. As a rule, it
does not last longer than 6 to 8 hours in a multipara and 12 hours in a primipara.
Figure 5.1
Dilation curvein the primipara
(in a multipara, the curve is shifted to the left)

123456789 1 0 1 1 1 210
9
876543210
Duration of labour
in hourDilation in cmNormal de livery and procedures re lated to vaginal delivery
855

Second stage: delivery of the infant
Begins after engagement, at full dilation.
Third stage: delivery of the placenta
See Chapter 8.
5.1.4 First stage: dilation and descent of the foetus
The indicators be ing monitore d are noted on the partograph (Section 5.2).
Uterine contractions
– Contractions progressively increase in strength and frequency: sometimes 30 minutes apart
early in labour; closer together (every 2 to 3 minutes) at the end of labour.
–A contraction can last up to a mi nute.
–The uterus should relax between contracti ons.
–Watch the shape of the uterus in order to spot a Bandl ’s ring (Chapter 3, S ection 3.3.2).
General condition of the patient
– Monitor the pulse, blood pressure and tempe rature every 4 hours or more often in case
of abnormal ity.
–Ask the patient to empty her bl adde r regularly (e.g. every 2 hours).
– Keep the pati ent hydrated (offer her water).
– Encourage the patient to move about freely during labour. Position changes and walking
around help relieve the pain and favour foetal descent. Pain can also be relieved by
massage or hot or cold compresses. Mi dwife support helps manage pai n.
– Routinely insert an IV line in the following situations: excessively large uterus (macrosomia,
multiple pregnancy or pol yhydramnios), known anaemia and hyperte nsion.
Foetal heart rate
Foetal heart rate monitoring
Use a Pinard stethoscope or foetal Doppler, every 30 minutes during the active phase and
every 5 minutes during active second stage, or as often as possible. Listen to and count for at
least one whole minute immediately after the contraction. Normal foetal heart rate is 120 to
160 beats per minute.
The foetal heart rate may slow during a contraction. If it becomes completely normal again as
soon as the uterus relaxes, there is no foetal distress.
If the foetal heart rate heard immediately after the end of a contraction is abnormal (less than
100 beats per minute or more than 180 beats per minute), continue foetal heart rate
monitoring for the next 3 contractions to confirm the abnormality.
Management of abnormal foetal heart rate
–In all cases:
•Insert an IV l ine.
•Check vital signs: pul se, blood pressure and temperature.
•Check the uterine tonus. If hypertonic, the problem might be a placental abruption or
excessive admi nistration of oxytoci n, which should therefore be stopped.
• Check the colour of the amniotic fluid: meconium-stained (greenish) amniotic fluid
combined with foetal heart rate abnormal ities is suggestive of true foetal di stress.Chapter 5
86

−If the foe tal heart rate is less than 100/mi nute:
•Stop admi nistering oxytocin if an i nfusion is in progress.
• Check for vaginal bleeding: bleeding may suggest placental abruption or uterine
rupture.
• Raise the patient or place her on her left side. Laying on her back the uterus creates
pressure on the vena cava, which may be the cause of low foe tal heart rate.
• Corre ct possible hypotension by fluid replaceme nt (Ringe r lactate ) to bring the diastolic
blood pressure to ≥ 90 mmHg.
• Pe rform a vagi nal exami nation to look for cord prol apse.
−If the foe tal heart rate is more than 180/mi nute:
The most common cause is maternal febri le infection.
• Treat the fever responsible for the foetal heart rate problems (paracetamol).
• Look for the cause of the infection (pyelonephritis, malaria, etc.) and treat.
• In case of fever of unknown origin, administer antibiotics as for a prolonged rupture of
membranes (Chapter 4, Section 4.9).
If the abnormal foetal heart rate persists or the amniotic fluid becomes stained with
meconium, deliver quickly. If the cervix is fully dilated and the head engaged, perform
instrumenta l delivery (vacuu m extracto r or forceps , dependin g on the operator’s skill and
experience); othe rwise consider caesarean secti on.
Dilation
– The cervix should remain soft, and dilate progressively. Dilation progresses at an average
rate of one cm per hour, and should be checked by vaginal examination every 2 to 4 hours
(Figures 5.2).
– No progress in ce rvical dilation betwee n two vagi nal exami nations is a warning si gn.
– Action may be taken when dilatation has not progresse d for 2 hours, and must always be
take n if it has not progressed for 4 hours: artificial rupture of the membranes, oxytocin
infusion, caesarean secti on, depending on the ci rcumstances.
5.2a: 1 finger = 1.5 cm 5.2b: 2 fingers = 3 to 3.5 cm
Figures 5.2
Estimating cervi cal dilation
Amniotic sac
–The amniotic sac bulges during contractions and usually breaks spontaneously after 5 cm
of dilation or at full dilation during delivery. Immediately after rupture, check the foetal
heart rate and if necessary perform a vaginal examination in order to identify a potential
prolapse of the umbilical cord (Section 5.4). Once the membranes are ruptured, always
use sterile gloves for vagi nal exami nation.!
Normal de livery and procedures re lated to vaginal delivery
875

– Note the colour of the amni otic fluid: clear, blood-stained, or meconi um-stained.
Meconium staining by itself, without abnormal foetal heart rate, is not diagnostic of foetal
distress, but does require closer monitoring—in particular, a vaginal examination every
2hours. Action must be taken if di lation fails to progress after 2 hours.
Foetal progress
– Asse ss foetal descent by palpating the abdome n (portion of the foetal head felt above the
symphysis pubis) be fore performing the vagi nal examination.
–At each vaginal examination, in addition to dilation, check the presentation, the position
and the degree of foetal descent.
–Look for signs that the foe tal head is engage d:
On vaginal examination, the presenting part prevents the examiner's fingers from reaching
the sacral concavity (Figures 5.3a and 5.3b). The presence of caput (benign diffuse swelling
of the foetal head) can lead to the mistaken conclusion that the foetal head is engaged.
The distance between the foetal shoulder and the upper edge of the symphysis pubis is less
than 2 finger widths (Figure s 5.3c and 5.3d).
5.3a: Prese nting part not engage d:
finge rs in the vagina can reach the sacral concavi ty
5.3b: Presenting part engaged:
fingers in the vagina cannot reach the sacral concavi ty
(if caput absent)!
!
Chapter 5
88

5.3c: Head not engaged: the shoulder 5.3d: Head engaged: the shoulder
is more than 2 finger widths is lessthan 2 finger widths
above the symphysis above the symphysis
Figures 5.3
Diagnosing engagement
– Use reference points on the foetal skull to determine the position of the head in the
mother's pelvis. It is easie r to determine the position of the head after the membranes
have ruptured, and the cervix is more than 5 cm dilate d. Whe n the head is well flexed, the
anterior (diamond-shaped) fontanelle is not palpable; only the sagittal suture and the
posterior (triangular) fontanelle are. The posterior fontanelle is the landmark for the
foetal occiput, and thus helps give the foetal position. In most cases, once the head is
engaged, rotation of the head within the pelvis brings the foetal occiput under the
mother's symphysi s, with the posterior fontanel le along the anterior mi dline.
5.1.5 Second stage: delivery of the foetus
Fundal pressure is always contra-i ndicated.
This stage is often rapid in a multipara, and slowe r in a primipara. It should not, however,
take longer than one hour of pushi ng.
It is an active phase for the birth attendant, who should wear sterile gloves to monitor the
head's progress and guide the del ivery.
If there is a traditional delivery position and no specific risk for the mother or child has been
established, it is possible to assist a delivery in a woman on her back, on her left side,
squatting or suspended (Figures 5.4).
5.4a: Lying on left si de 5.4b: Lying on back
Figures 5.4
Delivery posi tions!
!
!
!
!
Normal de livery and procedures re lated to vaginal delivery
895

– Rinse the vulva and peri neum with clean wate r.
– Th e bladd er should be emp tied, natu rally if possible. In cases of urinary retention only,
insert a urinary catheter using sterile technique (sterile gloves; sterile, single use
catheter).
– Expulsive effort should be directed, and starte d whe n the patie nt is fully dilate d and feels
the urge to push. She should push during the uterine contraction. Pushing may be done
either with held breath (after a deep inhalation, glottis closed, abdominal muscles and
diaphragm contracted, directed toward the perineum) or with exhalation. Expulsive effort
is maintained for long as possi ble: in general , 2 to 3 pushes per contracti on.
– Between contractions, the woman should rest and breathe deeply. The birth attendant
should monitor the foe tal heart rate .
– The head begins to stretch the perineum, which becomes progressively thinner; the
vaginal opening distends, the labia spread apart, and the occiput appears. In a cephalic
presentation, the head usually emerge s occiput anterior: the infant is born looking down,
the occiput pivoting against the symphysis (Figures 5.5). The head goes into slight
extension. The birth attendant must guide this motion and preve nt any abrupt expulsive
movement, with one hand supporting the occiput. The other hand can support the chin
through the pe rineum. Cover the anal area with a compress (Figures 5.6).
During this final phase—an active one for the birth attendant—the woman should stop all
expulsive efforts and breathe deeply. With one hand, the birth attendant controls the
extension of the head and moves it slightly side-to-side, in order to gradually free the
parietal protuberances; if necessary, the chin can be l ifted with the right (Fi gure 5.7).
Figures 5.5
The different stages of occi put-anterior del ivery!
Chapter 5
90

Figures 5.6
Progressive delivery of the head
Figure 5.7
Bringing the pe rineum under the chi n
At the moment of delivery, the perineum is extremely distended. Controlling the expulsion
can help reduce the risk of a tear. Episiotomy (Section 5.8) is not routinely indicated. In anocciput-posterior delivery (Figure 5.8), where perineal distension is at a maximum,
episiotomy may be he lpful.
Figure 5.8
Occiput-posterior del ivery!
!
!
Normal de livery and procedures re lated to vaginal delivery
915

The head, once delivered, rotates spontaneously by at least 90°. The birth attendant helps
this moveme nt by grasping the head in both hands and exerting gentle downward traction
to bring the anterior shoulder under the symphysis and then delive r it then, smooth upward
traction to deliver the posterior shoulder (Figures 5.9).
To reduce the risk of perineal tears, control the delivery of the posterior shoulder.
5.9a: Delivery of the anterior shoulder: 5.9b: Delivery of the posterior shoulder:
exert downward traction until smooth upward traction
the shoulder appears
Figures 5.9
Delivery of shoulders
The newborn normally cries immediately (within a minute of delivery). Place it on mother'schest.
5.1.6 Oxytocin administration
Administe r oxytocin to the mother immediately and then delive r the placenta (Chapter 8,
Section 8.1.2).
5.1.7 Umbilical cord clamping
– Delay clamping the cord (2 minutes), in all newborn crying vigorously, especially if weigh
is less than 2500 g, to re duce the risk of ne onatal anae mia.
– Clamp the cord with two Koche r force ps 10 cm from the umbilicus and cut betwe en the
2 force ps. Use sterile blade or scissors – a different pair than were used for episiotomy, if
performed.
– Tie off the cord with a Barr clamp or sterile thread (double ligature), leaving a 2- to 3-cm
stump.
–If neonatal resusci tation is needed, clamp and cut the cord i mmediately.
For newborn care, see Chapter 10.!
Chapter 5
92

5.2 Monitoring labour and delivery
5.2.1 Partograph
The partograph is a tool for monitoring maternal and foetal wellbeing during labour, and a
decision-making aid when abnormalities are detected. It is designed to be used at any level
of care.
The partograph begins with the active phase of labour, starting at 4 cm of dilation, and
3 contractions every 10 minutes. It should be filled in regularly during labour.
Its central feature is a graph used to record the progress of cervical dilation, as determined
by vaginal examination.
The partograph also includes other indicators to be entered on the graph each time they are
checked:
– Maternal indicators:
• Vital signs (heart rate, blood pressure and temperature)
• Time of spontaneous or artificial rupture of the membranes• Uterine contractions (number per 10 minutes and duration)• Urine output• Administration of any drugs (oxytocin, antibacterial, etc.)
– Foetal indicators:
• Foetal heart rate • Amniotic fluid (colour, odour and quantity)•Descent of the foetal head and head moulding
Interpreting the partograph
The WHO partograph (see following page) has two diagonal lines: an alert line and an action
line.
The alert line goes from 4 to 10 cm and corre sponds to an average dilation rate of 1 cm per
hour. If the labour curve crosse s to the right of this line, this means that the dilation is slow
(less than 1 cm/hour).
The action line is locate d 4 hours to the right of the alert line. If the dilatation curve crosses
this line, action must be taken.
If the alert line is crossed, transfer to the hospital must be considered if the woman is at an
outpatient clinic or a BEmONC facility. If the woman is at a CEmONC facility, either
immediate i ntervention or, at a mi nimum, closer moni toring is requi red.
If the action line is crossed, decisions (augmentation of labour, artificial rupture of
membranes, caesarean secti on, etc.) must be made. See Chapter 7.Normal de livery and procedures re lated to vaginal delivery
935

The WHO partograph
!
Chapter 5
94

5.2.2 Postpartum maternal monitoring in the delivery room
– Vital signs (pulse, blood pressure, temperature and respiratory rate), blood loss and
uterine retracti on:
• Betwe en Hour 0 and Hour 2: every 15 to 30 mi nutes,
• Betwe en Hour 2 and Hour 4: every hour.
– Verify that the patient drinks and uri nates.
– Check if there are other treatment indications, e.g., antibiotic therapy for prolonged
rupture of membranes (Chapter 4, Section 4.9.3), treatment of anaemia (Chapter 4,
Section 4.1), etc.
–In case of caesarean se ction, see Chapter 6, Se ction 6.4.
For monitoring and care following the immediate postpartum, see Chapter 11, Section 11.2
and11.4.Normal de livery and procedures re lated to vaginal delivery
955

5.3 Artificial rupture of the membranes (amniotomy)
Rupture of the amniotic sac using an amnihook (or, if not available, the claw from half of a
Kocher force ps).
5.3.1 Indications
–To speed up di lation.
–To speed up delivery once the cervix is fully dilated.
–As an adjunct to oxytocin for induction of labour (Chapter 7, Section 7.3.2).–To try to stop the bleeding during labour in case of partial placenta praevia (be careful not
perforate the placenta).
5.3.2 Precautions
– Polyhydramnios (risk of cord prolapse): re-examine immediately after rupture to make
sure that the cord did not end up below the he ad.
– Use sterile technique (infection risk as a result of opening the amniotic cavity to
pathogens).
– In case of prolonged rupture of membranes: antibiotic prophylaxis (Chapter 4, Section 4.9).
5.3.3 Contra-indications
Absolute
– Complete placenta praevi a
–Transverse lie
Relative
– Dilation l ess than 4 cm, i rregular contractions (false labour).
– Bre ech presentation prior to ful l dilation (keep the amni otic sac intact as long as possi ble).
–HIV or hepatitis B infection (or conte xt of high-prevalence ) prior to full dilation: keep the
amniotic sac intact as long as possi ble to reduce the risk of mothe r-to-child transmi ssion.
– Presenting part not engaged: risk of cord prol apse.
5.3.4 Technique
(Figure 5.10)
– Place the woman on her back with knees bent and thighs apart.
–Wear sterile gloves.
–Swab the perineum and the vagina with 10% polyvidone iodine.
– With one hand, prepare access to the sac (hand well into the cervix). With the other hand,
slide the amnihook between the fingers of the first hand—which spreads the vagina and
the cervix and guides the tip—and make a small cut in the sac as it bulges during a
contraction. Let the fl uid drain sl owly then, use a finger to enlarge the openi ng.Chapter 5
96

– Note the colour of the amniotic fluid (clear, greenish, or blood-staine d). Isolated meconial
staining, in the absence of an abnormal foetal heart rate, is not diagnostic of foetal
distress, but require s closer monitoring—in particular, vaginal examination every 2 hours.
If there is thick meconium-staine d fluid, there is a risk of aspiration at birth; be prepared
to suction the i nfant.
– Mak e sure the cord has not prol apsed.
– Che ck the foetal heart rate be fore and after amni otomy.
Figure 5.10
Artificial rupture of me mbranes!
Normal de livery and procedures re lated to vaginal delivery
975

5.4 Prolapsed cord
The umbilical cord drops in front of the presenting part, usually when the membranes
rupture (due to low insertion or excessive length, transverse or breech presentation, sudden
rupture of the amni otic sac, excess amni otic fluid, twin pregnancy).
Compression of the cord betwe en maternal tissue s and the foetus (Figure s 5.11 and 5.12)
during contractions causes foe tal distress and rapid foe tal death.
Figure 5.11
Cord coming out of the vagi nal opening
Figure 5.12
Compression of the cord by the presenting part
5.4.1 Diagnosis
– Amniotic sac has ruptured: cord can be felt between the fingers and, if the foetus is still
alive, pulsations can be fel t.
– Foetal distress: foetal heart rate is slow and i rregular.!
!
Chapter 5
98

5.4.2 Management
Foetus dead or nonviable (extremely premature)
No specific intervention, vaginal delivery, no caesarean section.
Foetus alive
This is an obste tric emergency, del iver immediately:
– The woman in knee-chest (Figure 5.13) or Trendelenburg (dorsal decubitus, head down)
position to take the pressure off the cord.
– With one hand inserted into the vagina, push the presenting part toward the uterine
fundus to relieve pressure on the cord, and hold until caesarean section.
– Caesarean section, holding the presenting part off of the cord via the vagina until
extraction. Check for a foetal heart rate right before the procedure. If foetal heart tone is
no longer heard, it is better to let vaginal delivery proceed (the infant is already dead).
– If the presenting part is engaged and the cervix fully dilated, it will not be possible to push
the presenting part back; perform vaginal extraction quickly: instrumental delivery (vacuum
extractor or forceps, Section 5.6) or total breech extraction (Chapter 6, Section 6.3).
Figure 5.13
Knee -chest posi tion!
Normal de livery and procedures re lated to vaginal delivery
995

5.5 Nuchal cord
The umbilical cord is looped around the neck of the foetus; this can cause foetal distress and
halt the progress of birth after delivery of the head.
Nuchal cord does not become visible until after the head is delivered.If the loop is loose, slip it over the infant's head.If the loop is tight and/or has several turns, clamp the cord with 2 Kocher forceps and cut
between the 2 forceps (Figure 5.14). Unwind the cord, complete the delivery and resuscitatethe newborn, if necessary.
Note: the possibility of a nuchal cord is the reason why 2 Kocher forceps and a pair of
scissors must be ready at the time of de livery.
Figure 5.14
Cut between 2 forceps as soon as the head is del ivered
!
Chapter 5
100

5.6 Instrumental delivery
The choice of extraction instrument (vacuum extractor or forceps) depends on the experience
and skill of the operator.
The condi tions for use are the same for both i nstruments:
– Full dilation.
– Regular ute rine contracti ons.
– Ve rtex presentation, head engaged.
– Accurate diagnosis of the head posi tion.
– Amniotic sac rupture d.
– Bladde r empty.
5.6.1 Vacuum extractor
(Figures 5.15)
Flexion and traction device for facilitating delivery of the foetus.There are various models, but all have:
–A metal or plastic suction cup, which must be sterilized between each patient;– A connection to a vacuum system controlled by a pressure gauge. The vacuum is
produced by means of a manual pump or electrical device;
–A handle for applying traction.
Figures 5.15
Models of vacuum extractor
!
!
!
!
!
!
Normal de livery and procedures re lated to vaginal delivery
1015

Indications
– Failure to progress due to insufficient or ineffective expulsive effort despite good uterine
contractility (using oxytocin, if necessary) with overly long delivery (more than 30 to
45minutes).
– Foetal distress (profound slowing in foetal heart rate) during delivery.
– Perineum unable to stretch enough (combine with episiotomy).
– Difficulty with extraction during caesarean section (if possible, use a Vacca Reusable
OmniCup-type vacuum extractor with built-in pump).
Contra-indications
– Breech, transverse, face or brow presentati on.
– Preterm infant: the bones of the skull are too soft.
–Head not engaged.– Cervix not fully dilated.
Technique
– Place the woman on her back with knees bent and thighs apart.–Swab the perineum and the vagina with 10% polyvidone iodine.–Empty the bladder (insert a sterile catheter).–Prepare the sterile part of the instrument (the cup), using sterile gloves.– Insert the cup into the vagina (Figures 5.16) and apply it to the scalp, as close as possible
to the posterior fontanelle—that is, anteriorly for occiput anterior presentations.
– With one hand holding the cup, circle the cup with one finger of the other hand to make
sure that no vaginal or cervical tissue is caught under it. Applying traction can tear the
cervix or vagina if there is vacuum extractor suction on those tissues (risk of massive
haemorrhage ).
Figures 5.16
Inserting the cup into the vagi na
–If required have an assistant connect the cup to the vacuum system.
– Hold the cup to the infant's head with one hand.
–Pump until the negative pressure reaches 0.2 kg/cm
2. Check again for trapped vaginal or
cervical tissue, then pump to reach a negative pressure of at most 0.8 kg/cm2.
Sit on a small foot rest or kneel; this gives a good traction angle and helps to stay
balanced. The traction, applied with the dominant hand, should be perpendicular to the
plane of the cup. !
Chapter 5
102

– Traction should be applie d in sync with the uterine contractions and the pushing, which
the patient should continue. Stop pulling the moment the uterine contraction stops. The
direction of traction varies according to the head's progress: first downward, then
horizontal, then i ncreasingly verti cal (Figure s 5.17).
–If the cup is positione d incorrectly or the traction too sudden, the cup can come loose. If
this happens, re-apply i t.
– When the one hand is able grasp the foetus' chin, turn off the suction, remove the
vacuum extractor and fi nish the de livery in the normal fashi on.
– While episiotomy is not routine, it can be useful, especially if the perine um is too resistant
or too distended.
Note: when there is a significant pre-existing caput, application of the vacuum extractor can
be ineffective and forceps may be necessary.
Do not apply suction for more than 30 minutes: the indication is probably incorrect, and
there is a risk of scalp ne crosis. Birth usual ly occurs in l ess than 15 mi nutes.
Make no more than 3 attempts at traction if there is no progress (the mother's pelvis is
probably i mpassable).
In case of fai lure, perform a caesarean secti on.
Figures 5.17
Vacuum extractor traction: axis varies depending on the progress of the head!
Normal de livery and procedures re lated to vaginal delivery
1035

Chapter 5
1045.6.2 Forceps
The use of forceps requires special expertise , and forceps should be used by trained birth
attendant onl y.
Forceps can be used even without the mothe r pushing; this is not possible with the vacuum
extractor.
Indications
–As for vacuum extraction.
– Bre ech presentation with re tention of the aftercoming he ad.
Contra-indications
–Transverse l ie or brow presentati on.
–Head not engaged.
– Cervix not ful ly dilated.

5.7 Symphysiotomy
Partial incision of the ligaments of the symphysis pubis such that the two pubic bones
separate by about 2 cm, al lowing enough room for passage of an entrappe d, live foetus.
This procedure should be done in combination with episiotomy (Section 5.8) and
instrumental de livery (Section 5.6).
5.7.1 Indications
This life-saving technique may be useful as a procedure of last resort:
–In situations where caesarean section is indicated but not feasiblea:
•Head engaged and arrested for more than an hour, and vacuum extraction alone has
already failed or is likely to do so.
• Foeto-maternal disproportion due to a pelvis that is slightly too narrow: after the trial
of labour has failed, and at least 3/5 of the head has descended into the pelvic cavity.
–In case of shoulder dystocia when other manoeuvres have failed.
–In case of entrapped aftercoming head in a breech when other manoeuvres have failed.
5.7.2 Conditions
– Me mbranes ruptured, ful l dilation (mi nimum 9 cm).
– The foetal head is not palpable above the symphysis pubis or by less than 2/5 (Figures 5.18).
5.7.3 Contra-indications
–Head not engage d.
–Brow presentati on.
–Dead foetus (in this case , perform an embryotomy, Chapte r 9, Section 9.7).
– Cervix not suffi ciently di lated.
– Severe cephalopelvic disproportion, with head above the symphysis by more than 2/5
(Figures 5.18).
Head not above Borderline superi or Frankly pal pable above the
to the symphysi s symphysis: contrai ndication
Figures 5.18
Position of the foetal head
aCaesarean section is not feasible because: surgical conditions are inadequate or surgical intervention would
take too long or there is a high risk of trauma to mother and foetus or the woman refuses caesareansection.!
Normal de livery and procedures re lated to vaginal delivery
1055

Chapter 5
5.7.4 Equipment
– Scalpel, suturing e quipment, delivery set with e pisiotomy sci ssors
–Vacuum extractor
– Foley cathe ter
– Sterile drape , compresses and gl oves
–10% polyvidone i odine
– Material for l ocal anae sthesia (1% l idocaine)
5.7.5 Technique
– Patient in lithotomy position, abduction supported by two assistants who maintain an
angle of less than 90° between the pati ent's thighs (Figure 5.19).
– Asepsis: shave the pubis; swab the pubic and peri neal region with 10% pol yvidone i odine.
– Place a steri le fenestrated drape over the symphysi s.
– Inse rt the Fol ey cathete r, which allows location of the urethra throughout the procedure .
– Local anaesthesia: 10 ml of 1% lidocaine , infiltrating the skin and subcutaneous tissues
superior, anterior, and inferior to the symphysis, along the midline, down to the ligament.
Infiltrate the episiotomy region as wel l.
– With the index and middle finge rs of the hand inserte d into the vagina, push the urethra
to the side (Figures 5.20 and 5.21). Place the index finger in the groove formed by the
cartilage between the two pubic bones, in such a way that it can feel the scalpel's
movements. The catheterized urethra must be pushed out of scal pel's reach.
– Incision:
•Locate the upper edge of the symphysi s.
• Introduce the scalpel 1 cm below this point, perpendicular to the skin, exactly on the
midline.
•Cut down until the cartilage: it should feel elastic; if it feels bony, gently withdraw the
blade and recheck the l ocation.
• First tilt the blade toward the top, use a small back-and-forth motion (Figure 5.22),
always along the midline, and in that way section 2/3 of the cartilage to the upper edge
of the symphysi s, going slightly past i t.
• Then, turn the blade around toward the bottom, and repeat the sectioning manoeuvre
down to the lowe r edge. The procedure is complete whe n the pubic bones move apart.
The assistants continue to hold apart the thighs making sure they do not move further
apart: the widening of the symphysis pubis must not exce ed 2 to 2.5 cm (the width of a
thumb).
–Do not cut the vagi na.
–Perform an epi siotomy; use a vacuum extractor to de liver the infant.
–One or two stitches suffice to close the wound after del ivery.
Figure 5.19
Supported l ithotomy posi tion!
106

Figure 5.20
Finger pushing the urethra out of the way
Figure 5.21
Finger pushing the head and urethra out of the way
Figure 5.22
Scalpel moves back and forth!
!
!
Normal de livery and procedures re lated to vaginal delivery
1075

5.7.6 Post-operative care
–Have the mothe r rest on her side (avoid force d abduction of the thighs) for 7 to 10 days.
Mobilization with aid is possible as of Day 3 if the woman can tolerate the discomfort. No
heavy work for 3 months.
– If there was blood in the urine during catheterization, the foetal head probably
compressed and injured the bladd er wall: leave the cathet er in place for 10 to 14 days
after the haematuria re solves. Otherwi se, remove it i mmediately.
– Routine treatment for pain as for cae sare an section (Chapter 6, S ection 6.4.5).
5.7.7 Complications
– Bleeding at the si te of the wound: compression bandage.
– Local infection: daily dressings and antibiotics ( amoxicillin PO: 3 g/day in 3 divided doses
for 5 days).
– Stre ss incontinence : uncommon and temporary.
– Gait problems: prevented through bed re st.
–Injury to the urethra or bladder: leave the catheter in place for 10 to 14 days and consult
a specialist.
– Osteitis: e xtremely rare if rigorous steri le technique has been used.Chapter 5
108

5.8 Episiotomy
Incision on the pe rineum
5.8.1 Indications
Episiotomy is a source of infection and/or haemorrhage and should not be done routinely.
Simple first- and second-degree tears heal as well or better than an episiotomy.
Episiotomy should be routinely performed in the following situations:
– Symphysiotomy– Occiput posterior, face, or breech delivery in a primipara
Episiotomy should be considered in the following situations:
– Delivery is taking more than 30 minutes, especially if foetal heart rate slows, when
completion of the de livery is being obstructed by the pe rineum.
– Instrumental del ivery (forceps or vacuum extracti on).
– Shoulde r dystocia.
– Occiput posteri or, face, or breech del ivery in a mul tipara.
–Oedematous or scarred peri neum that does not stretch properl y.
– History of third and fourth degree te ars.
– Excision (clito ral circumcision with partial or total clitoridecto my, often with remo val of
the labia minora). Excision cause s a loss of perineal elasticity, with a risk of a prolonged
delivery and perineal tears. Episiotomy may be nece ssary but may not completely prevent
tearing.
5.8.2 Equipment
– Delivery sets contai ning 2 pairs of sci ssors
–10% polyvidone iodine, sterile compresses– Material for local anaesthesia (1% lidocaine)
5.8.3 Technique
–Swab the pe rineum with 10% pol yvidone i odine.
– Administer local anaesthesia by infiltration with 10 ml of 1% lidocaine .
– Perform the episiotomy when the perineum is thinned and widened, distended by the
foetus, which appears at the vaginal opening: during a push, make a straight 4 cm cut
using sterile scissors, obliquely down and out at a 45% angle from the posterior vulvar
commissure. Protect the foetus with the other hand (Figure 5.23).
–The episiotomy can be done to the right or the left, depending on whether the operator is
right- or l eft-handed.
– The scissors used for the episiotomy, now contaminated, should be put aside
immediately. They must not be used for other procedures, like cutting the cord (this is
why all delivery sets must i nclude 2 pairs of sci ssors).Normal de livery and procedures re lated to vaginal delivery
1095

Figure 5.23
Cutting the perineum
To suture the perineum, see Section 5.9.!
Chapter 5
110

5.9 Perineal repair
During delivery the perineum can tear causing different degrees of vulvovaginal lacerations:
superficial (first-degree tear), or deeper, affecting the muscle tissue (second-degree tear,
equivalent to an episiotomy).
All genital mutilations – that is, clitoral circumcision (Type I mutilation), clitoral circumcision
with removal of the labia minora (Type II mutilation), and infibulation (Type III mutilation,
Section 5.10) – are associ ated with a risk of peri neal tears during expul sion.
Two adjacent tissues may also be damage d:
– The anal sphincter muscle, which is red and fleshy. A tear in this sphincter can be
recognized by the loss of the anus' radial appearance (third-degree tear). Repair of the
muscle is essenti al to prevent faecal i ncontinence.
– The rectal mucosa, which is smooth and whitish, extending from the anus. A tear in rectal
mucosa (fourth-degree tear) must be sutured to prevent anal fistula with incontinence
and infection.
5.9.1 Equipment
–Suture set contai ning steri le scissors, di ssecting forceps and needle hol der
–10% polyvidone iodine
– Local anaesthe sia (1% lidocaine)
– One or two Dec3 (2/0) absorbable sutures
–A rapidly absorbable suture for closing the skin or, if not available, a non-absorbable Dec3
(2/0) suture
– Sterile drape and gl oves
–If needed, make a tampon from sterile compresse s tied togethe r with a thick thread; this
is inserted into the vagina to absorb the endo-uterine bleeding (Figure 5.24). The pull
string, visible at the vulva, prevents forgetting the tampon when the proce dure is over.
Ordinary compresses may be used in place of this tampon.
–Good lighting
Figure 5.24
Tampon made of compresses tied together with a pul l string!
Normal de livery and procedures re lated to vaginal delivery
1115

5.9.2 Technique
The perineum should not be sutured unti l after the pl acenta is del ivered.
–Swab the pe rineum and vagina with pol yvidone i odine 10%.
– Position a ste rile aperture drape .
– Asse ss the size and number of tears. If episiotomy was performed, check to make sure it
did not tear further, and look for other tears. If necessary, use vaginal retractors to
expose the enti re vaginal wall.
–Use local anaesthesia (lidocaine 1%) in all the involved tissues except the rectal mucosa.
For complex and/or third- or fourth-degree tears, do not hesitate to do the suturing in the
operating room under general or spinal anaesthesia.
Superficial vulvar tears (first-degree)
–If they are not bleeding and confined to the area near the vaginal opening: basic care, no
suturing.
– If they are bleeding or deep: continuous simple or simple interrupted suture using
absorbable suture materi al.
Episiotomy or simple second-degree perineal tears
– Locate the apex of the cut/tear and place a first stitch the re if necessary.
– Suture the vaginal mucosa going from the inside out, to just behind the hymenal
remnants, using a continuous or interrupted figure-of-eight absorbable suture; stitches
should be close enough to prevent lodging of lochia in the following days, but not too
deep, to avoid going into the rectum (Figure 5.25).
– Next, suture the muscle layer with two or three absorbable figure-of-eight sutures
(Figure 5.26).
– Close the skin with rapidly absorbable or non-absorbable suture material, using interrupted
(simple or vertical mattress) stitches; begin by placing the first stitch, without tying it, on the
posterior commissure (Figure 5.27) . Because the tissues will be oedematous in the days
following the birth, avoid tying the knots too tight. Do a rectal examination to make sure
that no stitches can be felt in the rectum. Remove compresses from inside the vagina.
Figure 5.25 Figure 5.26 Figure 5.27
Suturing the mucosa Suturing the muscl e Suturing the ski n
Rupture of the anal sphincter
–A tear in the muscular ring can result in retraction of the two torn ends of the muscle,
now hidden in the tissues. Insert a finger into the rectum to locate the two ends.
– Suture the sphincter with two or three absorbable figure-of-eight or horizontal mattress
sutures (Figure 5.28).
– Continue in the same sequence as in the preceding case.
Chapter 5
112

Figure 5.28
Suturing the anal sphincter
Tear in the rectal mucosa
–Protect the wound from faecal material by placing a compress in the rectum (as with the
vaginal tampon, do not forget to remove i t).
–Swab with polyvidone iodine 10%.
–Suture the rectal mucosa, going from high to low, using absorbable, interrupted stitches
knotted on the rectal surface (Figures 5.29).
– Continue in the same sequence as in the preceding case.
Figures 5.29
Suturing the rectal mucosa
5.9.3 Post-operative care
–In all cases, the vulva should be cleansed with soap and water and dried when the patient
urinates or defecates, at least twice dai ly.
–For nonabsorbable sutures: remove the stitches between the 5thand 8thday.
– Routine analgesia: paracetamol and/or ibuprofen (especially if there is perineal oedema).
A short course of ibuprofen can be prescribed in breastfeeding women (maximum
5days).
– For third- and especially fourth-degree tears, recommend a fibre-free diet (no fruits or
vegetables) for two weeks, if possible. If necessary, give a laxative to prevent passage ofhard stools over the sutured rectal mucosa.!
!
Normal de livery and procedures re lated to vaginal delivery
1135

– No antibiotics are needed for an episiotomy or perineal tear. For fourth-degree tears,
administe r metronidazole PO: 1.5 g/day in 3 di vided doses for 5 days.
5.9.4 Management of complications
Haematoma
– Remove the stitches and drai n.
–If there are no signs of infection and the bleeding has stopped, re-suture the episiotomy
either completely or partially (to allow spontaneous drainage), or leave a drain in place.
Infection
– Remove the stitches, drain and, if ne cessary, remove non-vi able tissues
– Minor infection: no antibiotic; drainage is enough.
– Severe infection: antibiotic therapy for 5 days ( amoxicillin PO: 3 g/day in 3 divided doses
+metronidazole PO: 1.5 g/day in 3 di vided doses).Chapter 5
114

5.10 Deinfibulation
Infibulation or Type III mutilation refers to clitoral circumcision with partial or complete
removal of the clitoris, often combined with removal of the labia minora, in addition to
vulvar occlusion with partial or complete removal of the labia majora, the edge s of which
are sealed together. All that is left is a residual opening at the base of the vulva for the
passage of uri ne and menstrual bl ood.
Infibulation may interfere with the ability to monitor cervical dilation and with the normal
childbirth process.
It can cause prolonged retention of the foetus against the perine um, increasing the risk of
severe mate rnal tissue damage (tears and fi stula) and the risk of foe tal distress and death.
Deinfibulation, performe d during pregnancy or labour, may be necessary for the birth of the
child. Doubl e episiotomy is not an acceptable substitute for de infibulation.
5.10.1 Equipment
–Suture set contai ning: steri le scissors, dissecting forceps and nee dle holder
– Antiseptic (10% pol yvidone i odine)
– Local anaesthe sia (1% lidocaine)
– One or two Dec3 (2/0) absorbable sutures
– Sterile drape and gl oves
5.10.2 Technique
–Ask the patient to uri nate.
– Administe r local anae sthesia.
–Swab the pe rineum and vagina with 10% pol yvidone iodine.
–Insert one fi nger of one hand in the opening in the vulva to protect the ure thra.
– With the other hand, use scissors to cut the midline anterior strip of scar tissue; this
allows access to the vagina and urethra.
–Ensure haemostasis with a continuous suture along each e dge.
After delivery, the opening of the vulva allows free passage of urines and lochias. Women
should never be re-i nfibulated.
Postoperative care is i dentical to that for a peri neal tear or epi siotomy.Normal de livery and procedures re lated to vaginal delivery
1155

Chapter 6:
Special deliveries
6.1 Breech presentation …………………………………………………………………………………119
6.1.1 The different breech presentations ……………………………………………………..119
6.1.2 Diagnosis …………………………………………………………………………………………119
6.1.3 Management ……………………………………………………………………………………120
6.1.4 Breech delivery problems …………………………………………………………………..122
6.2 Twin pregnancy ……………………………………………………………………………………….126
6.2.1 Diagnosis …………………………………………………………………………………………126
6.2.2 Management during pregnancy ………………………………………………………….126
6.2.3 Management during delivery ……………………………………………………………..126
6.3 Total breech extraction …………………………………………………………………………….128
6.3.1 Relative contra-indication ………………………………………………………………….128
6.3.2 Technique ………………………………………………………………………………………..128
6.4 Caesarean section …………………………………………………………………………………….130
6.4.1 Indications ……………………………………………………………………………………….130
6.4.2 Prerequisites for performing a caesarean …………………………………………….130
6.4.3 Pre-operative care …………………………………………………………………………….130
6.4.4 Peri-operative care ……………………………………………………………………………131
6.4.5 Post-operative care…………………………………………………………………………..1316

6.1 Breech presentation
Presentation of the feet or buttocks of the foetus.
6.1.1 The different breech presentations
–In a complete breech presentation, the legs are tucked, and the foetus is in a crouching
position (Figure 6.1a).
–In a frank breech presentation, the legs are extended, raised in front of the torso, with the
feet near the head (Figure 6.1b).
–In a footling breech presentation (rare), one or both feet present first, with the buttocks
higher up and the lower limbs extended or half-bent (Figure 6.1c).
6.1a 6.1b 6.1c
Complete breech Frank breech Footling breech
Figures 6.1
The different breech presentations
6.1.2 Diagnosis
– The cephalic pole is palpable in the uterine fundus; round, hard, and mobile; the
indentation of the neck can be fel t.
–The inferior pole is vol uminous, irregular, less hard, and less mobi le than the head.
– During labour, vaginal examination reveals a “soft mass” divided by the cleft between the
buttocks, with a hard projection at end of the cleft (the coccyx and sacrum).
–After rupture of the membranes: the anus can be felt in the middle of the cleft; a foot
may also be fel t.
– This is sometimes a difficult diagnosis: a hand may be mistaken for a foot, a face for a
breech.!
Special del iveries
1196

6.1.3 Management
Route of delivery
Before labour, external version (Chapter 7, Section 7.7) may be attempted to avoid breech
delivery.
If external version is contra-indicated or unsuccessful, the breech position alone – in the
absence of any othe r anomaly – is not, strictly speaking, a dystocic presentation, and does
not automatically require a caesarean section. Deliver vaginally, if possible – even if the
woman is primiparous. The risks of caesarean section to the mother for both the current
and future pregnancies are greater than the risk to the infant of foetal distress during a
bree ch vaginal delivery.
Breech deliverie s must be done in a CEmONC faci lity, especially for pri miparous women.
Favourable factors for vagi nal delivery are:
–frank breech presentati on;
–a history of vagi nal delivery (whatever the pre sentation);
– normally progre ssing dilation during labour (more than 1 cm/hour).
The footling breech presentation is a very unfavourable position for vaginal delive ry (risk of
foot or cord prolapse). In this situation, the route of delivery will be determine d based on
the number of previous births, the state of the membranes and how far advanced the
labour is.
During labour
– Monitor labour every hour: the cervix must di late steadi ly by 1 cm/hour.
– If contractions are of good quality, dilation is progressing, and the foetal heart rate is
regular, an expectant approach is best. Do not rupture the membranes unless dilation
stops.
–If the uterine contractions are i nadequate , labour can be acti vely managed with oxytoci n.
Note: if the dilation stales, transfe r the mothe r to a CEmON C facility unless already done, to
ensure access to surgi cal facility for pote ntial caesarean se ction.
At delivery
– Inse rt an IV line before expulsion starts.
– Routinely perform episiotomy at expulsion for primiparous women, and whe n there is any
concern in multiparous women. Episiotomy is performed when the perineum is
sufficiently distended by the infant's buttocks.
– Presence of meconium or meconium-stained amniotic fluid is common during breech
delivery and is not necessari ly a sign of foetal di stress.
–The infant delivers unaided, as a result of the mother's pushing, simply supported by the
birth attendant's hands, with no traction. Do not pul l on the legs.
Once the umbilicus is out, the rest of the delivery must be completed within 3 minutes,
otherwise compression of the cord wi ll deprive the infant of oxygen.
Do not touch the infant until the shoulder blades appear to avoid triggering the
respiratory reflex before the head is del ivered.
– Monitor the posi tion of the infant's back; impede rotation into posterior posi tion.Chapter 6
120

Figures 6.2
Breech delivery!
Special del iveries
1216

6.1.4 Breech delivery problems
Posterior orientation
If the infant’s back is posterior during expulsion, take hold of the hips and turn into an
anterior posi tion (this is a rare occurrence ).
Obstructed shoulders
The shoulders can become stuck and hold back the infant's upper chest and head. This can
occur whe n the arms are raised as the shoulde rs pass through the mother's pelvis. There are
two methods for l owering the arms so that the shoul ders can desce nd:
1 – Lovset's manoeuvre (Figures 6.3):
• With thumbs on the infant's sacrum, take hold of the hips and pelvis with the other
fingers.
• Turn the infant 90° (back to the left or to the right), to bring the anterior shoulder
underne ath the symphysis and engage the arm. Del iver the anterior arm.
• Then do a 180° counter-rotation (back to the right or to the left); this engages the
posterior arm, which is then de livered.
6.3a 6.3b
Turning the infant to bring down Downward traction and descent of shoul ders
the anterior shoul der along the mi dline (sacral -pubic) axi s
6.3c
Delivering the anterior arm and shoul der
Figures 6.3
Lovset's manoeuvre!
!
Chapter 6
122

2 – Suzor’s manoeuvre (Figures 6.4), in case the previous method fails:
•Turn the infant 90° (its back to the right or to the left).
• Pull the infant downward: insert one hand along the back to look for the anterior arm.
With the operator thumb in the infant armpit and middle finger along the arm, bringdown the arm (Figure 6.4a).
• Lift infant upward by the feet in order to deliver the posterior shoulder (Figure 6.4b).
6.4a
Bringing down the anterior arm
6.4b
Delivering the posterior shoulder
Figures 6.4
Suzor’s manoeuvre
Head entrapment
The infant's head is bulkier than the body, and can get trapped in the mother's pelvis or soft
tissue.
There are various manoeuvres for delivering the head by flexing it, so that it descends
properly, and then pivoting it up and around the mother's symphysis. These manoeuvres
must be done without delay, since the infant must be allowed to breathe as soon as
possible.!
!
Special del iveries
1236

1 – Bracht's manoeuvre (Figures 6.5):
• After the arms are delivered, the infant is grasped by the hips and lifted with two
hands toward the mother's stomach, without any traction, the neck pivoting around
the symphysis.
• Having an assistant apply suprapubic pressure facilitates deli very of the aftercoming
head.
Figures 6.5
Bracht's manoeuvre
2 – Modified Mauriceau manoeuvre, in case the previous method fai ls (Figures 6.6):
•Infant's head occiput anteri or.
• Kneel to get a good traction angle: 45° downward.•Support the infant on the hand and forearm, then insert the index and middle fingers,
placing them on the infant’s maxilla. Placing the index and middle fingers into the
infant’ s mouth is not recommended, as this can fracture the mandi ble.
• Place the index and middle fingers of the other hand on either side of the infant's
neck and lower the infant's head to bring the sub-occiput under the symphysis
(Figure 6.6a).
• Tip the infant’s head and with a sweeping motion bring the back up toward the
mother's abdomen, pi voting the occiput around her symphysis pubis (Figure 6.6b).!
Chapter 6
124

• Suprapubic pressure on the infant's head along the pelvic axis helps delivery of the
head.
• As a last resort, symphysiotomy (Chapter 5, Section 5.7) can be combined with the
Mauriceau manoeuvre .
All these manoeuvres must be performed smoothl y, without traction on the i nfant.
6.6a – Step 1
Infant straddles the birth attendant's forearm; the he ad, occiput ante rior,
is lowere d to bring the occiput in contact with the symphysi s.
6.6b – Step 2
The infant's back is tipped up toward the mother's abdomen.
Figures 6.6
Modified Mauriceau manoeuvre!
!
!
!
!
!
!
Special del iveries
1256

6.2 Twin pregnancy
Simultaneous development of two foetuses in the uteri ne cavity.
6.2.1 Diagnosis
–The diagnosis is suspected in the second half of pregnancy when the uterus is abnormally
large.
–Two poles of the same type (e.g., two heads) or three pol es are felt.
–Two distinct foetal heart beats are he ard.
–The diagnosis can be confirmed by ul trasound.
6.2.2 Management during pregnancy
– Close monitoring, more freque nt antenatal consultations, screening for and management
of complications such as anaemi a, placenta praevi a, prematuri ty, and pre-ecl ampsia.
– Reduction in the mother's l evel of physi cal activity.
6.2.3 Management during delivery
Twin deliverie s should take place in a CEmONC faci lity, if possible.
Delivering the first twin
– Inse rt an IV line before expulsion starts.
– Deliver in the same way as a si ngleton.
–When the cord is cut, leave a clamp on the placenta side, as there may be an anastomosis
with the second twin's ci rculation.
– Never administer oxytocin for active management of the third stage of labour before the
second twin is delivered.
Rest period
– Usually 15 minutes; should not exceed 30 minutes. Take advantage of the pause in
contractions to study the presentation of the second twi n.
– Immediately after delivery of the first twin, an assistant should hold the second twin in a
vertical position by placing hands laterally on either side of the uterus. This is done to
prevent the foetus from assuming a transverse l ie, in the now loo large uterus.
–If the presentation is normal , await spontaneous del ivery.
– If contractions have not resumed after 15 minutes, administer an escalating-dose
oxytocin i nfusion ( Chapter 7, Section 7.4) to speed up the birth of the second twi n.
Delivering the second twin
– If presentation is longitudinal (vertex or breech): proceed as with a normal vertex or
breech del ivery. Del ivery of the second twin is usual ly faster.Chapter 6
126

–For a transverse lie, attempt external version (Chapte r 7, Section 7.7) or perform internal
version (Chapter 7, Section 7.8) if conditions are favourable (full dilation, soft uterus) to
bring the foetus to a breech posi tion, then perform total breech extraction (Section 6.3).
Note: delivery is usually easier if the first twin is in vertex presentation. Vaginal delive ry is
still possible, however, when the first twin is breech. Twins who are locke d at the chin is a
rare complication, seen when the first twin is breech and the second verte x. If this occurs,
attempt to continue the vaginal delive ry. The mortality and morbidity among such twins is
high.
Delivering the placenta
–After the second twin is born, admi nister:
•oxytocinroutinely: 5 to 10 IU by IM or slow IV i njection;
•cefazolin or ampicillin slow IVa: 2 g as a single dose if internal manoeuvres were
performed.
– There is a significant risk of haemorrhage due to uterine atony. If there is any doubt,
perform manual removal of pl acenta and/or ute rine cavity expl oration.
aFor patients with a history of immediate hypersensitivity reaction to penicillin (urticaria, respiratory
problems or oedema): clindamycin IV, 900 mg as a si ngle dose.Special del iveries
1276

6.3 Total breech extraction
Breech extraction of the second twin when the condition of the foetus requires rapid
extraction (foetal di stress); may be preceded by i nternal ve rsion for transverse foetal l ie.
This technique requires experience in obstetrical manoeuvres. If possible, it should be
performed in a CEmONC facility. Prepare for a caesarean section in case the total breech
extraction fai ls.
6.3.1 Relative contra-indication
–Scarred uterus (risk of uteri ne rupture)
6.3.2 Technique
– Routinely insert an IV l ine.
–Empty bladder.
– Proceed slowly; it may be necessary to pause periodically to allow the uterus to re-soften. – Insert a hand into the uterus and bring down one foot. –Do not rupture the membranes right away (they will rupture on their own when the foot
is pulled down, or will be ruptured artificially once the foot is down).
– Delivering the foot:
Complete breech (Figures 6.7a and 6.7c)
•Grasp one or both ankles with one hand, index and middle finger straddling the back of
the foot;
• Apply gentle traction to bring the leg to the vulva.
Frank breech (Figures 6.7b and 6.7c)
•Grasp a single foot, and bring it down by bending the knee until the lower leg is against
the thigh, then continue bringing it down until the leg is fully extended;
•If a hand is grasped rather than a foot, push it back up and start over (feel for the bend
at the ankle).
– Delivering the breech (Figures 6.8)
• Apply gentle, continuous, downward traction on the leg to deliver the anterior hip, the
infant's back ante riorly.
•Once the anterior hip has been delivered, pull gradually upward to deliver the posterior
hip.
•Once the pelvis is out, with thumbs on the loins, take hold of the hips and pelvis with
the other fingers. Pull the pelvis downward, keeping the back anterior, until the tips of
the shoulder blades are seen.
– Deliver the shoulders and head: Lovset and Bracht manœuvres (Section 6.1.4).
– Explore the uterus to rule out uterine rupture.
– Routine antibiotic prophylaxis after clamping the cord:
cefazolin or ampicillin slow IVb, 2 g
as a single dose.
bFor patients with a history of immediate hypersensitivity reaction to penicillin (urticaria, respiratory
problems or oedema): clindamycin IV, 900 mg as a si ngle dose.Chapter 6
128

6.7a 6.7b
Grasping one or both feet Grasping the anterior foot
in the complete breech in the frank breech
6.7c
Bringing one foot down
Figures 6.7
Total breech extraction
6.8a 6.8b
Downward traction Upward traction
to deliver the anterior hip to deliver the posterior hip
Figures 6.8
Delivery of the breech in a total breech extraction!
!
!
!
Special del iveries
1296

6.4 Caesarean section
Performing a caesarean section requires technical expertise and good obstetric knowledge
for determining appropriate indications. There can be difficulties (haemorrhage, difficulty
extracting the foetus, etc.) and complications (bladder injury, uterine tear, foetal trauma,
etc.). Compared to vaginal delivery, caesarean section is associated with higher maternal
mortality and an increased risk of complications for future pregnancies, regardless of the
setting in which it is pe rformed.
6.4.1 Indications
Absolute, because life-threatening to the mother (1 to 2% of al l deliveries)1
– Severe, uncontrol led ante-partum bl eeding (tachycardia and hypotensi on).
– Malpresentation that cannot be turned (shoul der, brow or chi n-posterior face).
– Absolute foeto-pelvic disproportion (partograph showing a failure to progress in the
active phase of labour despite good uterine dynamics) and no possibility of instrumental
extraction.
– Uterine rupture .
– History of 3 or more caesarean secti ons.
Relative
The decision to perform caesarean section should consider the risk/benefit for the mother
and the infant in the given context: access to services and the availability and level of
neonatal care.The risks to the mothe r should be evaluated in the short term (death, infection, thrombo –
embolism, etc.) and the medium/long term (future uterine rupture, placenta praevia or
accreta during another pregnancy, etc.). In low-resource contexts with difficult access to
services and a high fertility rate, both the immediate and the medium and long term risks to
the mother often outweigh the potenti al benefits to the i nfant.
6.4.2 Prerequisites for performing a caesarean
– Skilled human resources for determining whether surgery is indicated, administering the
anaesthesia and performing the surgery.
– Appropriate facilities (operating room, sterilisation, post-operative recovery room and
blood transfusi on).
– Appropriate equi pment.
– Appropriate care and moni toring.
6.4.3 Pre-operative care
– Patient’ s consent.
– Anaesthesia eval uation.
– Routine prophyl axis against gastric acid aspi ration:
cimetidine PO (effervescent tablet): 200 mg in 30 ml of water, 20 minutes prior to surgeryChapter 6
130

6.4.4 Peri-operative care
–Standard skin pre paration.
– Foley catheter insertion.
– Routine antibiotic prophylaxis:
cefazolin slow IVc: 2 g as a single dose (to be preferably administere d 15 to 60 minutes
prior to incision, otherwise, at incision)2, EXCEPT if prolonged rupture of membranes,
maternal fever, frank chorioamnionitis, peritonitis, infected or prolonged uterine rupture
or septic shock. In the se cases, admi nister the appropri ate antibiotic the rapyd.
– Administration of oxytocin:
•10 IU by slow IV injection routinely after clamping the cord
Then•20 IU in 1 litre of Ringer lactate administered over 2 hours at a rate of 160 drops per
minute (in the event of persistent haemorrhage, up to 60 IU maximum).
6.4.5 Post-operative care
– Close initial moni toring:
Vital signs, bleeding, analgesia, etc. in the recovery room.
Transfer to i npatient unit after consul ting anae sthetist.
– Analgesics (by oral route whenever possi ble):
• Routine anal gesics on a fixed schedule:
Day 0 to Day 1, tramadol : 50 mg every 8 hours
Day 0 to Day 3, ibuprofen : 400 mg every 8 hours
Day 0 to Day 5, paracetamol : 1 g every 6 hours
Adjust according to the pain self-assessment. If necessary, add morphine : 10 mg every
4 hours.
• Routine, regular pain self-assessme nt (self-assessme nt scale): see the MSF handbook,
Clinical guidelines.
• Respect the contra-indications; avoid non-steroidal anti-inflammatory drugs in
situations where clotting and renal function may be compromised (sepsis, pre-
eclampsia).
The surgeon may infiltrate the wound at the end of the procedure with levobupivacaine
0.5% (150 mg or 2 mg/kg, maximum 30 ml); this provides increased pain relie f in the first
4 to 8 hours after surge ry.
– Thromboprophylaxis:
Not done routinely for uncomplicated caesarean sections. Desirable, with a low-
molecular-weight hepari n, in the event of:
•caesarean section with hysterectomy;
• history of deep vein thrombosi s;
• two risk factors for thromboembolism (infection, prolonged labour, pre-eclampsia,
severe bl eeding or si ckle cell disease).
– Infusion and IV catheter:
If uncompl icated caesarean secti on:
•Day 0: 1 l itre of 5% glucose and 1 l itre of Ringer lactate over 24 hours.
•Day 1: remove the IV catheter.
cIn patients with a history of immediate hypersensitivity reaction to penicillin (urticaria, respiratory problems
or oedema): clindamycin IV, 900 mg as a si ngle dose.
dIntrauterine foetal death, tinged or meconium-stained amniotic fluid and an initial attempt to extract
vaginally are not i ndications for anti biotic therapy.Special del iveries
1316

– Feeding:
• Spinal anaesthesia: fluids may be resumed 2 hours post-operatively.
• General anaesthesia: fluids may be resumed 4 hours post-operatively.• Uncomplicated caesarean section (no hysterectomy or pelvic peritonitis): light meal
may be given 6 hours post-operatively. It is not necessary to wait until the patient
passes gas.
– Urinary cathe ter:
Routine catheter removal on Day 1, unl ess:
• Blood-stained urine when catheter is removed.• Urine output < 500 ml/24 hours.
• Peri/post-operative complication (wait to consult the surgeon and/or anae sthetist).
– Early mobi lisation:
•Day 0: mobi lisation at the edge of the bed begi nning 6 hours post-operati vely.
•Day 1: patient out of bed for the first ti me.
– Dressing and suture removal :
•If hygiene conditions are good: uncover wound on Day 1.
• Otherwise , remove dressing on Day 5 (or at discharge if stay less than 5 days). There is
no need to change the dressing every day.
•Remove skin sutures (if not absorbabl e) on Day 7.
– Cleaning:
Simple shower; no i ntravaginal cl eansing.
– Breast-feeding:
• Begin bre ast-feeding as soon as possi ble.
• Monitor the infant (risk of drowsi ness if the mother re ceives tramadol or morphi ne).
– Documentation:
• Operative report.
•On discharge: give patie nt a document specifying the reason for the caesare an section
and the type of hysterotomy performe d (classical/low transverse), to aid in deciding the
route of del ivery for a subsequent pregnancy.Chapter 6
132

References
1UON Network. Tackling Unmet Need for Major Obstetric Interventions. Concepts,
General Pri nciples and Internati onal Network.
http://www.uonn.org/pdf/Guide1.pdf
2Sullivan SA, Smith T, Chang E, et al. Administration of cefazolin prior to skin incision is
superior to cefazolin at cord clamping in preventing postcesarean infectious morbidity: a
randomized, controlled trial. Am J Obstet Gynecol 2007; 196; 455.e1-455.e5.Special del iveries
1336

7Chapter 7:
Labour dystocia and malpresentations
7.1 Prolonged labour ……………………………………………………………………………………..137
7.1.1 Diagnosis …………………………………………………………………………………………137
7.1.2 Management ……………………………………………………………………………………137
7.2 Obstructed labour ……………………………………………………………………………………140
7.2.1 Diagnosis …………………………………………………………………………………………140
7.2.2 Possible causes …………………………………………………………………………………140
7.2.3 Complications …………………………………………………………………………………..140
7.2.4 Management ……………………………………………………………………………………140
7.2.5 Prevention/management of vaginal fistulae …………………………………………141
7.3 Labour induction ……………………………………………………………………………………..142
7.3.1 Indications ……………………………………………………………………………………….142
7.3.2 Methods ………………………………………………………………………………………….142
7.3.3 Conditions………………………………………………………………………………………..143
7.4 The use of oxytocin during labour ……………………………………………………………..145
7.4.1 Indications ……………………………………………………………………………………….145
7.4.2 Risks of using oxytocin during labour …………………………………………………..145
7.4.3 Contra-indications to the use of oxytocin during labour …………………………145
7.4.4 Situations requiring special precautions ………………………………………………145
7.4.5 Conditions for oxytocin use ………………………………………………………………..145
7.5 Shoulder dystocia …………………………………………………………………………………….147
7.5.1 Management ……………………………………………………………………………………147
7.5.2 Methods of last resort ……………………………………………………………………….148
7.6 Transverse lie and shoulder presentation …………………………………………………..149
7.6.1 Diagnosis …………………………………………………………………………………………149
7.6.2 Possible causes …………………………………………………………………………………150
7.6.3 Management ……………………………………………………………………………………150
7.7 External version ……………………………………………………………………………………….152
7.7.1 Conditions………………………………………………………………………………………..152
7.7.2 Contra-indications …………………………………………………………………………….152
7.7.3 Technique ………………………………………………………………………………………..152
7.8 Internal version ……………………………………………………………………………………….154
7.8.1 Indications and conditions ………………………………………………………………….154
7.8.2 Technique ………………………………………………………………………………………..154

7.9 Face presentation ……………………………………………………………………………………156
7.9.1 Diagnosis ………………………………………………………………………………………..156
7.9.2 Management …………………………………………………………………………………..156
7.10 Brow presentation …………………………………………………………………………………..159
7.10.1 Diagnosis ………………………………………………………………………………………159
7.10.2 Management …………………………………………………………………………………160

7.1 Prolonged labour
Excessively prolonged dilation or delivery. The term “prolonged labour” applies only at or
after 4 cm dilation and 3 contractions per 10 minutes. Before that point, it is usually a
question of “fal se labour” (i.e. prol onge d latent phase).
Prolonged labour can be due to foeto-pelvic disproportion (mechanical dystocia) and/or
inadequate contractions (dynamic dystoci a).
The main risks of prolonged labour are obstruction (Section 7.2) and foetal di stress.
7.1.1 Diagnosis
– Protracted cervical dilation (dilation progresses less than 1 cm/hour during the active
phase);
or
– The foetus has failed to engage after more than 1 hour of complete dilation in a multipara
and 2 hours of complete di lation in a pri mipara;
or– The active pushing phase until birth of the infant is longer than 30 minutes in multipara
and 1 hour in pri mipara.
7.1.2 Management
See algorithms on fol lowing pages.
For general patient care during labour, see Chapter 5, Section 5.1.4.
Notes:
– Oxytocin is contra-indicated in case of frank foeto-pelvic disproportion (risk of uterine
rupture).
– In case of foetal distress (prolonged deceleration of the foetal heart rate to less than
100 beats per mi nute after each ute rine contraction) and if the foetus is vi able:
• At complete dilation, with the presenting part engaged: instrumental delivery (Chapter 5,
Section 5.6);
• Prior to complete dilation, or at complete dilation with presenting part not engaged:
consider caesarean section earlier than in the algorithms, but the context needs to be
taken into account when deciding a caesarean section for exclusive foetal indication
(Chapter 6, Section 6.4).
In either case, do not use—or stop, if already usi ng—oxytocin.
– If the foetus is dead, avoid caesarean section whenever possible. Allow more time for
dilation and engagement. Consider embryotomy ( Chapter 9, Section 9.7).Labour dystocia and mal presentations
1377

Management of protracted cervical dilation
Crossing of the partograph action l ine
or more than 4 hours at the same di lation
For other presentations, see Breech presentation (Chapter 6, Section 6.1), Transverse lie and
shoulder presentation (Section 7.6 ), Face presentation (Section 7.9 ), Brow presentation
(Section 7.10).Chapter 7
138Membranes
intactMembranes
ruptured
Amniotomy
Reassess after
1 hour
Frank
foetopelvic
disproportion
No oxytoci n
Caesarean secti onVertex prese ntation
Asse ss pelvis
Asse ss descent of the head
No foetopel vic
disproportion or
mode rate disproportion
Good uteri ne
contractionsInadequate uteri ne
contractions
Reasse ss after
2 to 4 hours,
if no progress:
Oxytocin for
2 to 4 hours
Dilation
not progressi ng:
caesare an sectionDilation
progressing we ll:
vaginal de livery

Management of protracted foetal descent at complete dilation
No engagement after 1 hour (multipara) and 2 hours (primipara) and/or no delivery
despite good expulsive efforts after 30 minutes (multipara) and 1 hour (primipara)
For other presentations:
–Breech presentation: caesarean section or, in rare cases, manoeuvres (do not attempt any
manoeuvre on a non-engaged breech);
–Shoulder, chin-posterior face, or brow presentation: caesarean section.Labour dystocia and mal presentations
1397Engaged Not engaged
Empty the bl adder
Vacuum extraction ± episiotomy
or even symphysiotomy.
Do not perform fundal pressure.Obvious F-P
disproportion
No oxytoci n
Caesarean
sectionVertex presentation
Asse ss pelvis
Asse ss descent of the headGood ute rine
contractionsInadequate uteri ne
contractions
Oxytocin No F-P
disproportion
Improve foetal head posi tion:
bring posterior fontanelle
(occiput) upward. Oxytocin for 1 hour.
Vaginal del ivery
Caesarean secti on
in case of fai lureEngagement:
vaginal
deliveryNo
engagement:
caesarean
section

7.2 Obstructed labour
Active labour which lasts longer than 24 hours, sometimes several days.
7.2.1 Diagnosis
– Dehydration.
– Possible hypovolaemic shock.– Patient dazed, anxious, agitated, in pain.– Imminent uterine rupture (pathological retraction ring, hourglass shape, see Chapter 3,
Section 3.3).
– Amniotic i nfection: fever, foul -smelling amni otic fluid.
– Distended bl adder.
–On vaginal examination:
• oede matous cervi x;
• depending on the presentati on:
Vertex: caput that may reach the vaginal opening, but vertex itself not engaged and
pelvis seems narrow;Breech: re tention of aftercoming he ad;
Transverse: negl ecte d shoulder, prolapsed arm and hand.
–Foetus often dead or in l ife-threatening condi tion.
7.2.2 Possible causes
– Foeto-pelvic disproportion (including malpresentations and praevia obstructions).
– Pushing with an incompletely dilated cervix.
7.2.3 Complications
– Uterine rupture .
– Uterine infection, septicaemia, peritonitis.– Compression injuries to the bladder and rectum, leading to the formation of fistulae.– High maternal and foetal mortality.
7.2.4 Management
– Insert an IV line (16-18G catheter), fluid resuscitation (Ringer lactate or 0.9% sodium
chloride).
–Insert a urinary catheter, if it is possible without damaging the urethra. Otherwise, insert
suprapubic catheter. Relieving the bladder distension is sometimes enough to produce
delivery.
– Depending on the cause of the obstruction and the medi cal equipment avai lable:
•The foetus is al ive and vi able: caesarean secti on.
• The foetus is non-viable or if there is no possibility of caesarean section: symphysiotomy,
episiotomy and vacuum extracti on.
•The foetus is dead: embryotomy.
– Antibiotic therapy for prolonged rupture of membranes or a rupture of unknown duration
(Chapter 4, Section 4.9) and for chorioamnionitis (Chapter11, Section 11.4.2).Chapter 7
140

– There is a significant risk of postpartum haemorrhage due to uterine atony: if active
management of third stage labour fails, quickly perform manual removal of placenta then,
administe r oxytocin.
– Speculum exami nation: if ti ssue necrosis, excision under steri le conditions.
– Perineal and vulvar toi let, 2 times dai ly.
7.2.5 Prevention/management of vaginal fistulaea
– Encourage the patient to drink 4 to 5 l itres of water per day.
– Leave the urinary catheter in place for 14 days, then:
•If there is no fistula: remove the urinary catheter.
• If the fistula is ≤ 4 cm diameter, attempt conservative treatment. Leave the urinary
catheter in place for at least 4 to 6 weeks to allow fistula to heal. Keep the catheter in
place as long as the fistula is not closed and as long as a gradual decrease of its
diameter is observed at each we ekly inspection.
•If the fistula is > 4 cm diamete r or the conservative treatment fails or the patie nt has
fistula for over 3 months, re fer or register the patient for surgi cal treatment.
aFor more information on vaginal fistulae, see: Guiding principles for clinical management and programme
development Obstetric Fistula. World Health Organization, Geneva 2006.
http://whqlibdoc.who.int/publications/2006/9241593679_eng.pdf?ua=1Labour dystocia and mal presentations
1417

7.3 Labour induction
Triggering labour arti ficially be fore it begins natural ly.
Broadly speaking, induction is a two-ste p sequence: the first part involves cervical ripening
(effacement, mid-position, early dilation), the second, induction of contractions that dilate
the cervix.
7.3.1 Indications
Induction of labour is not an emergency proce dure. It should be done only when there is a
clear indication, in a CEmON C facility (refer if necessary) to allow rapid intervention in the
event of compl ications (e.g., uteri ne rupture or foe tal distress).
When referral to a CEmONC facility is not possible or there is limited (or no) foetal monitoring,
indications are restri cted to the fol lowing situations:
– Intrauterine foetal death (Chapte r 4, Section 4.11);
− Maternal i ndication for termi nation of pregnancy and non-vi able foetus;
− Se vere pre-eclampsia and ecl ampsia (Chapter 4, Se ction 4.5 and 4.6);
−Premature rupture of me mbrane s with risk of i nfection (Chapte r 4, Section 4.9).
Notes:
– Prolonged pregnancy (over 41 weeks LMP) is traditionally considered an indication for
inducing labour; this is not made in practice, however, due to the frequent uncertainty
about the due date.
− Suspected foetal macrosomia at term is not an indication for induction.
7.3.2 Methods1
Administration of prostaglandins
misoprostol 200 micrograms tabl et:
25 micrograms PO (dissolve one tablet in 200 ml of water and give 25 ml of this solution)every 2 hours until good contractions are obtained; do not exceed 150 micrograms total
dose;or50 micrograms vaginally into the posterior fornix (a quarter tablet) every 6 hours until good
contractions are obtained; do not exceed 150 micrograms total dose.
Note: dose of misoprostol is different in case of intrauterine foetal death (Chapter 4,
Section 4.11).
or
dinoprostone gel: 1 mg vaginally into the posterior fornix. A second dose may be
administered after 6 hours if the patient has not gone into l abour.
Wait 6 hours2after the last dose of prostagl andins before using oxytocin during l abour.Chapter 7
142

Artificial rupture of membranes and administration of oxytocin
Artificial rupture of membranes (Chapter 5, Section 5.3) is performed while applying gentle
pressure (if needed) on the head through the abdomen to prevent cord prol apse.
Administration of oxytocin alone
This is not as effecti ve as the other me thods, but may be used i f:
– Prostaglandins are not available;
– Bishop score is ≥ 6 (Table 7.1);– Artificial rupture of membranes is not feasible because the foetal head is too high.
Mechanical method using a Foley catheter balloon
Wear sterile gloves. With a speculum in place, insert a 16-18G Foley catheter into the
cervical canal, guiding it with finge rs or force ps. Inflate the balloon with sterile water in 10
ml increments until it is well inflate d in the cervix (30 ml, on average) and apply continuous
light pressure (catheter taped to the inner thigh) for 24 hours maxi mum.
Stripping the membranes
During the vaginal examination, if the cervix is open, insert one finger into the internal os
and separate the membranes with a circular motion. This can help start labour, or at least
cervical ri pening, in the fol lowing hours or days.
7.3.3 Conditions
The choice of induction method depe nds on the initial degree of cervical ripening. The riper
the cervix, the more effective and rapid the i nduction.
Asse ssment of the cervix is facilitate d by a scoring system for cervical ripening: the Bishop
score.
Table 7.1 – Bishop Score (the hi gher the score , the riper the cervi x)
Criteria 0 1 2 3
Cervical di lation (at the
internal os)closed 1 finger 2 fingers > 2 fingers
Cervical length long mid-length short effaced
Position of the foetal head
relative to the ischial spines,
in cm (foetal station)–3 –2 –1 or 0 +1 or +2
Cervical consi stency firm medium soft
Cervical posi tion posterior mid positionLabour dystocia and mal presentations
1437

The cervix is considered ripe, that is, favourable to induction, if the score is 6 or greater.
Labour is induced by arti ficially rupturing the me mbrane s and admi nistering oxytoci n.
If the cervix is unfavourable or unripe (score below 6, with at most a long, firm, posterior
cervix), ripen the cervix using a prostaglandin before triggering contractions with oxytocin
or, if prostagl andins are not avai lable, use a mechani cal method and then oxytoci n.
Special situations
–Scarred ute rus:
•Foetus al ive and vi able : prostagl andins are contra-i ndicated:
– if the cervix is unfavourabl e: mechani cal induction and oxytocin or caesarean se ction;
– if the cervix is favourable: arti ficial rupture of membranes and oxytocin at hal f-dose.
•Foetus al ive but non-vi able: as for i ntrauterine foe tal death.
– Intrauterine foetal death: see Chapte r 4, Section 4.11.Chapter 7
144

7.4 The use of oxytocin during labour
7.4.1 Indications
– Induction of l abour.
– Correction of a dynamic dystocia: delayed dilation in a woman in labour, with arrest for
more than 2 hours , due to inadequat e uterin e contractions. The cervix must be dilated
more than 3 to 4 cm, and effacement in progress. The membranes must have been
ruptured.
– Contractions fai l to resume 15 minute s after the birth of a first twi n.
7.4.2 Risks of using oxytocin during labour
– Maternal risk: uterine rupture, especially in a scarred uterus, but in a sound uterus as
well, particularly if it is overdistende d (multiparity, polyhydramnios, multiple pregnancy)
or if there is major foeto-pel vic disproportion.
– Foetal risk: foetal distress due to uterine hypertony (uterine contraction without relaxation).
7.4.3 Contra-indications to the use of oxytocin during labour
– Obvious foe to-pelvic di sproportion, including mal presentation (brow, transve rse, etc.).
– Complete placenta praevi a.
–Spontaneous ute rine hype rtony.
– Foetal di stress.
–Two or more prior cae sare an sections.
– Prior cl assical caesarean section (verti cal uterine incision).
–Absence of me dical indication.
7.4.4 Situations requiring special precautions
– Prior si ngle low transverse caesarean secti on.
–Grand multiparity.
– Overdistended uterus.
Oxytocin may be used to correct a dynamic dystocia during labour, provided the following
conditions are respected:1) maximum infusion rate of 30 drops/minute for 5 IU in 500 ml;2) interval of at least 30 minutes between dose increases.
7.4.5 Conditions for oxytocin use
– Given the risk to both mother and foetus, use of oxytocin during labour requi res:
• close maternal monitoring (check for hyperstimulation, dystocia and imminent rupture
at least every 30 mi nutes);
• close foetal moni toring (check for decel erations in heart rate at least every 30 mi nutes);
• proximity to an operating theatre, in order to perform prompt caesarean section if
needed.
– Position the patient on her left si de.
In case of foetal distress, uterine hyperkinesia (more than 5 contractions in 10 minutes) or
uterine hypertony (absence of uterine rel axation): stop the oxytoci n.
After delivery, however, there is no risk of uterine rupture or foetal distress, and oxytocin
can be used more readi ly.Labour dystocia and mal presentations
1457

Chapter 7
146
Table 7.2 – Use of oxytocin
Indications Precautions before administration Technique Monitoring during administration
During labour
Labour induction • On vaginal exam, assess cervical dilation
and effacement, and e ngagement.
•The harder and more closed the cervix
and the higher the station, the harder
induction wi ll be.
• Verify the absence of foetal di stress.• Dilute 5 IU in 500 ml or 10 IU in 1 litre of Ringer lactate
or 0.9% sodium chloride.
• Start at 5 to 8 drops/minute, then increase by 5 to
8drops/minute every 30 minutes, until contractions are
effective (3 contractions of more than 40 seconds in
10minutes).
On average, 20 drops/minute results in satisfactory
uterine contractions. Do not exceed 60 drops/minute.
• Once the infant has delivered:
– use the existing IV line to administer the appropriate
dose of oxytocin for prevention of postpartum
haemorrhage;
– let the current i nfusion fi nish. • Appearance and quality of contractions,
uterine re laxation.
• Foetal heart rate .
• General condi tion of the mother.
• Cervical di lation.
Rupture the membranes as soon as
possible.If the woman has not gone into labour
after 8 hours: stop the infusion and start
again the next day, if delivery is not
urgent.
Correction of dynami c
dystocia • Cervix at least 3-4 cm on vagi nal exam.
• Spontaneous or artificial rupture of
membranes.
• No foeto-pel vic disproportion.As for labour i nduction. • Resumption or augmentation of con –
tractions, uterine relaxation.
• Foetal heart rate .
• General condi tion of the mother.
• Cervical di lation.
No contractions 15 mi nutes
rth of first twi n• Verify that presentation is vertical (not
transverse).•Start or resume oxytocin i nfusion.
• As for labour induction, but increase more rapidly:
5drops every 5 mi nutes.• Resumption or augmentation of con –
tractions, uterine relaxation.
• Foetal heart rate .
Note: outside of labour, oxytocin is use as below
Haemorrhage due to uteri ne
atony• First, manually remove the placenta, if
needed.
• Routine uterine exploration.IV infusion over 2 hours of 20 IU in 1 litre of Ringer
lactate or 0.9% sodium chloride at a rate of 160 drops/
minute. At the same me, give 5 to 10 IU by slow IV
injec on; repeat if necessary un l the uterus becomes
firm and contracted; do not exceed 60 IU total dose.•Heart rate, blood pressure, blood l oss.
• Uterine re traction.
After caesarean se 10 IU by slow IV i clamping the cord then
20 IU by IV infusion in 1 litre of Ringer lactate or 0.9%
sodium chloride over 2 hours at a rate of 160 drops/minute.• Uterine re traction.
Prevention of post-partumhaemorrhage • Verify that there is no 2ndtwin. 5 to 10 IU by slow IV or IM injec on, before or a er the
3rdstage, depending on staff exper se.

7.5 Shoulder dystocia
Delivery cannot progre ss after the head is out, because the shoulde rs are impacted in the
pelvis. Shoulder dystocia is especi ally common when the foetus is l arge.
This is a life-threatening emergency for the foetus (di stress, rapid death by asphyxi ation).
Additional assistants are require d. Explain the situation to the assistants and the patient to
obtain their coope ration.
7.5.1 Management
The HELPERR mnemonic is a useful tool for addressing this e mergency3:
H: Call for help.
E: Evaluate for episiotomy
Episiotomy is not routinely needed since the shoulder is impacted on the bony pelvis.
However, it can be performed to make more room for manoeuvres.The recommended time for attempting manoeuvres is 30 seconds to 1 minute each. Anassistant should inform the operator how much time has passed.
L: McRoberts manoeuvre (hyperflexion of the mother's thighs)
Ask two assistants to push the patient’s knees firmly toward her chest. This manoeuvre
alone is effective in releasing a shoulder in more than 70% of cases.
P: Suprapubic pressure
While maintaining the hyperflexion of the thighs, an assistant presses firmly just above the
symphysis pubis to try to reduce the diameter of the shoulders and lower the anterior
shoulder under the symphysis while the operator applies continuous downward traction on
the foetal head. Do not apply fundal pressure, as this will impact the shoulder and can result
in uterine rupture.
E: Internal manoeuvres
If this fails, perform internal rotation manoeuvres while maintaining the hyperflexion of the
thighs. There are several options, depending on whether there is easier access to the anterior
or posterior shoulder:
– Rubin’ s manoeuvre: insert the fingers of one hand behind the anterior shoulder and push
toward the foetal chest to try to free the shoul der.
− Wood’s corkscrew manoeuvre, to be combined with Rubin’s manoeuvre: place two
fingers of the free hand against the front of the posterior shoulder and apply pressure to
free the shoulders by turning (in a corkscrew manner).
−Reverse Wood’s corkscrew manoeuvre: si milar, but rotating in the opposite di rection.HCall for Hel p
EEvaluate for Episiotomy
L Legs (the McRoberts manoeuvre)
PSuprapubic Pre ssure
E Enter manoeuvres (i nternal rotati on)
RRemove the poste rior arm
RRoll the pati entLabour dystocia and mal presentations
1477

R: Remove the posterior arm
If this fails, bring down one foetal arm to reduce the diameter of the shoulders and allow
delivery:– Kneel to get the proper axis of traction.– Reach in to find the posterior arm, and bring it to the vaginal opening: slide a hand behind
the foetus' head and move it along his arm, trying to get hold of his hand. Grasp it anddraw it down along his abdomen to the vaginal opening. The delivery can then continue.
– If it is impossible to get hold of the hand, place two fingers along the humerus, like a
splint. Bend the elbow and sweep the humerus across the chest to bring down the arm.
R: Roll the patient onto her hands and knees
Roll the patient to “all-fours position”. The pelvic diameters increase in this position.
Carefully examine the vagina after these manoeuvres, since lacerations are common.
Above all, do not:
– Apply excessive traction to the foetal head, as this can rupture the brachial plexus on the
side of the anterior shoulder.
– Pivot the head by twisting the neck, as this can also cause neurological injury.
7.5.2 Methods of last resort
– General anae sthesia to relax the muscl es.
–Fracture of the foetal clavicle by direct pressure on the middle part of the clavicle.
– Symphysiotomy (Chapter 5, Section 5.7). – Embryotomy in case of foetal death and failure of the manoeuvres (Chapter 9, Section 9.7).
–Push the head back in (very di fficult), then perform caesarean secti on.!
Chapter 7
148

7.6 Transverse lie and shoulder presentation
A transverse lie constitutes an absolute foeto-pelvic disproportion, and vaginal delivery is
impossible.
This is an obstetric emergency, because labour is obstructe d and there is a risk of uterine
rupture and foetal di stress.
7.6.1 Diagnosis
– The uterus is very wide : the transverse axis is virtually equivalent to the longitudinal axis;
fundal height is l ess than 30 cm near term.
– On examination: head in one side, breech in the other (Figures 7.1a and 7.1b). Vaginal
examination reveals a nearly empty true pelvis or a shoulde r with—sometimes—an arm
prolapsing from the vagina (Fi gure 7.1c).
7.1a: Dorsoinferior (back down) 7.1b:Dorsosuperior (back up)
left shoulder presentation left shoulder presentation
7.1c: Neglected shoulder presentati on
Figures 7.1
Transverse l ie and shoulder presentati on!
Labour dystocia and mal presentations
1497

7.6.2 Possible causes
–Grand mul tiparity.
– Uterine malformation.
– Twin pregnancy.– Prematurity.– Placenta praevia.– Foeto-pelvic disproportion.
7.6.3 Management
This diagnosis should be made before labour begins, at the final prenatal visit before the
birth.
At the end of pregnancy
Singleton pregnancy
– External version 4 to 6 weeks before delivery, in a CEmONC facility (Section 7.7).
–If this fails, delivery should be carried out by caesarean section, either planned or at the
beginning of labour (Chapter 1, Section 1.3.2).
Twin pregnancy
– External version is contra-indicated.
–If the first twin is in a transverse lie (unusual): schedule a caesarean section.–If the second twin is in a transverse lie: there is no strict indication for caesarean section,
but plan delivery in a CEmONC facility so that it can be performed if necessary. Deliver thefirst twin and then, depending on the experience of the operator, perform externaland/or internal version on the second twin.
During labour, in a CEmONC facility
The foetus is alive and the membranes intact
– Gentle external version, between two contractions, as early as possible, then proceed as
with normal delivery.
–If this fails: caesarean section.
The foetus is alive and the membranes ruptured
– Complete dilation:
• Multipara with relaxed uterus and mobile foetus, and an experienced operator: internal
version and total breech extraction.
• Primipara, or tight uterus, or immobile foetus, or engaged arm, or scarred uterus or
insufficiently-experienced operator: caesarean section.
– Incomplete di lation: caesarean secti on.
Caesarean section can be difficult due to uterine retraction. Vertical hysterotomy is
preferable. To do the extraction , get hold of a foot in the fundus (equivalent to a total
breech extracti on, but by caesarean secti on).
The foetus is deadEmbryotomy for transverse l ie (Chapter 9, Section 9.7.7).Chapter 7
150

During labour, in remote settings where surgery is not available
The foetus is alive and the membranes intact
Try to refer the patient to a CEmONC facility. Otherwise:
–Attempt external version as early as possible.–If this fails, wait for complete dilation.– In order to perform version under the proper conditions, perform general or spinal
anaesthesia, depending on what is possi ble.
– Pe rform an external version (Section 7.7) combine d with an internal version (Section 7.8),
perhaps using various posi tions (Trende lenburg or kne e-chest).
The foetus is alive and the membranes ruptured
Try to refer the patient to a CEmONC faci lity. Othe rwise:
– Complete di lation:
•Put the woman into the knee-chest posi tion.
• Betwe en contracti ons, push the foetus back and try to engage his he ad.
• Vacuum extraction (Chapter 5, Section 5.6.1) and symphysiotomy (Chapter 5, Section 5.7)
at the slighte st difficulty.
– Incomplete di lation: Trende lenburg posi tion and watchful wai ting until complete dilation.
The foetus is dead
Try to refer the pati ent, even if referral takes some ti me.
Otherwise, embryotomy for transverse l ie (Chapter9, Section 9.7.7).Labour dystocia and mal presentations
1517

7.7 External version
A procedure to convert:
–a transverse lie into a longitudinal (cephalic or breech) presentation,or–a breech presentation into a cephalic presentation.
7.7.1 Conditions
–Pregnancy near term (37 weeks LMP).
– Prior to l abour, or at the very start of l abour.
– Relaxed uterus.– No obstacle to vaginal delivery.– Membranes intact.
External version is very rarely associated with complications. Complications have, however,
been reported (placental abruption, rupture of a scarred uterus and foeto-maternal
haemorrhage). Therefore, this manoeuvre should only be attempted in a CEmONC facility.
7.7.2 Contra-indications
Absolute
– Placenta praevi a.
– Twin pregnancy (for the first twi n).
Relative
– Foetal di stress.
– Se vere intrauterine growth restri ction.
– Prematurity.
–Scarred ute rus.
–HIV infection.
Note: in case of transverse lie whe n referral is not possible, in the interest of the mother
external version may be attempted to permit vaginal delivery, without taking into account
relative contra-indications.
7.7.3 Technique
–Woman l ying on her back, legs half bent, bladder empty.
–Perform when the uterus is relaxed.
– First, push back the breech or shoulder, which is often down in the pelvis (vertical
movement), then attempt rotation slowly, and always in the direction of foetal flexion:
thus bringing either the head or the breech to the pelvic inlet by the shortest possible
route (Figures 7.2).Chapter 7
152

– Monitor the foetal heart rate after each attempt, and stop if the rate slows. In most cases,
foetal heart rate abnormal ities improve within 30 mi nutes.
– External version should be fol lowed by 24 hours of bed rest and moni toring.
Figures 7.2
Version to convert a breech presentation to a cephal ic presentati on
Labour dystocia and mal presentations
1537

7.8 Internal version
Manual intrauterine proce dure to convert one presentation to another, usually a transverse
lie into a bre ech.
7.8.1 Indications and conditions
– Shoulder presentation during labour, at complete dilation with a relaxed uterus. This
manoe uvre should be performed with extreme caution (risk of uteri ne rupture).
– Delivery of a second twin in cephalic presentation or transverse lie: version to bring the
foetus into the breech position and allow a total breech extraction (Chapter 6, Section 6.3).
– Conditions necessary in all cases: normal pelvis, presenting part not engaged, bladder
empty.
– Grasping one or both feet is best done through membranes that have been left i ntact4.
7.8.2 Technique
– Strict ase psis: swab peri neum with 10% pol yvidone i odine, wear steri le gloves.
–Perform anaesthe sia if possi ble.
– Inse rt the hand and de termine the position of the foetus:
• with the fingers in the form of a cone, go through the vaginal opening and the cervix
toward the fundus;
• hold the fundus in pl ace with the other hand on the abdome n.
–Grasp one foot or if possible both feet, firmly, without haste but not too slowly, since a
prolonged manoeuvre might cause the uterus to contract (Figure 7.3a). It is better not to
rupture the membranes immediately because the uterine retraction and lack of amniotic
fluid will make it difficult to grasp and move the foetus. The membranes will spontaneously
rupture when pulling the foot or will be artificially ruptured once the foot is down.
– Pull the foot/feet gently to the vagi nal opening (Figure 7.3b).
–The delivery then continues as a bree ch delivery, ending with a total extraction if a twin,
or normal ly, if not.
– Manually explore the uterus after delivery of the placenta (to look for uterine rupture),
and administer routinely antibiotic prophylaxis (cefazolin or ampicillin slow IV: 2 g as a
single dose)b.
bFor patients with a history of immediate hypersensitivity reaction to penicillin (urticaria, respiratory
problems or oedema): clindamycin IV, 900 mg as a si ngle dose.Chapter 7
154

7.3a: Catch hold of one foot (preferably both fe et)
7.3b: Bring the foot/feet down to the vagi nal openi ng
Figures 7.3
Internal version
Labour dystocia and mal presentations
1557

7.9 Face presentation
7.9.1 Diagnosis
– Palpation of the mother's abdomen at the start of labour: palpate the occipital region; a
cleft between the head and the back wi ll be palpable, due to hype rextension of the head.
–On vaginal examination: no suture or fontanelle can be felt; orbits, nose, mouth, ears and
chin palpable. Pal pation of the chin is essenti al to confirm the di agnosis.
7.9.2 Management
Determine the ori entation of the chi n—anterior (at the mother's pubis) or posteri or.
The chin is anterior
Vaginal del ivery is possi ble. Labour may be sl ow, patience is requi red.
If uterine contractions are i nadequate, oxytocin may be use d.
Episiotomy is usually needed during delivery (Figure s 7.4), given the maximum amount the
perine um can stretch.
If instrumental delive ry is necessary, use force ps. Vacuum extraction is contra-indicated for
a live infant.
Figures 7.4
Chin anterior: del ivery possible
The chin is posterior
Vaginal delivery is not possible (Figure 7.5). A caesarean section must be arranged. Refer if
necessary.
Figure 7.5
Chin posterior: i mpaction
Chapter 7
156

If caesarean section is not feasible and referral is not possible, attempt the following
manoeuvres:
– Flex the head to obtain a verte x presentation: with one hand in the vagina, grasp the top
of the skull and flex the neck, using the other hand, on the abdomen, to apply pressure to
the foetal chest and buttocks. Obviously, the presenting part must not be engaged, and it
is often hard—or i mpossible —to keep the head fl exed (Figures 7.6).
Figures 7.6
Manoeuvre to convert face to vertex prese ntation
– Rotate the head to bring the chin anteriorly: push the face and chin back to free the
shoulders from the pelvic inlet then, turn the head within the pelvic cavity, using a hand
on the abdome n to help the rotation by applying pressure to the shoulders. In this way,
the chin is brought to the front (Figures 7.7).
Figures 7.7
Rotation manoeuvre to bring the chin anteri orly
Labour dystocia and mal presentations
1577

– Version: i nternal podal ic version, then total breech extraction (Fi gure 7.8).
Figure 7.8
Internal podal ic version
All these manoeuvres are difficult and pose a significant risk of uterine rupture . They must
be done when the uterus is not contracting. Whenever possible, perform caesarean section
instead.
Chapter 7
158

7.10 Brow presentation
Brow presentation constitute s an absolute foeto-pelvic disproportion, and vaginal delive ry is
impossible (except with preterm birth or e xtremely low birth we ight).
This is an obstetric emergency, because labour is obstructe d and there is a risk of uterine
rupture and foetal di stress.
7.10.1 Diagnosis
–Head is high; as with a face presentation, there is a cleft betwe en the head and back, but
it is less marked.
–On vaginal examination the brow, orbits, anterior fontanelle and, occasionally, the eyes
and bridge of the nose are pal pable (Figures 7.9). But it is not possi ble to pal pate:
•the chin (it is not a face presentati on),
•the poste rior fontane lle (it is not a vertex pre sentation).
Figures 7.9
Brow presentati on
Any mobile presenting part can subsequently flex. The diagnosis of brow presentation is,
therefore, not made until after the membranes have ruptured and the head has begun to
engage in a fixed presentation. Some brow presentations will spontaneously convert to a
vertex or, more rarel y, a face presentati on.
During del ivery, the presenting part is slow to descend: the brow is becoming i mpacted.
Labour dystocia and mal presentations
1597

7.10.2 Management
The foetus is alive
–Perform a caesarean section. When performing the caesarean section, an assistant must
be ready to free the head by pushing it upward with a hand in the vagi na.
–As a last re sort, if caesarean section is i mpossible, attempt two manoeuvre s:
• Conve rt the brow presentation to a face presentation: betwe en contractions, insert the
finge rs through the ce rvix and move the he ad, encouraging defl exion (Figures 7.10).
•Attempt i nternal podal ic version (Section 7.9).
Both these manoeuvres pose a significant risk of uterine rupture. Vacuum extraction,
forceps and symphysiotomy are contra-i ndicated.
Figures 7.10
Manoeuvre to convert brow to face presentati on
The foetus is dead
Perform an embryotomy if the cervix is sufficiently dilated (Chapter 9, Section 9.7);
otherwise, a caesarean secti on.
Chapter 7
160

References
1Word Health Organization. WHO recommendations for induction of labour. Geneva, 2011.
http://whqlibdoc.who.int/publications/2011/9789241501156_eng.pdf?ua=1
2Martindale – The Complete Drug Reference. Oxytocin (Last reviewed: 2011-05-10).
3Elizabeth G. Baxley, Robert W. Gobbo. Shoulder Dystocia. Am Fam Physician. 2004 Apr
1;69(7):1707-1714.
http://www.aafp.org/afp/2004/0401/p1707.html
4J Rabinovici, G Barkai, B Reichman, D M Serr, S Mashiach. Internal podalic version with
unruptured membranes for the second twin in transverse lie. Obstetrics and Gynecology;
1988; 71(3 Pt 1):428-30.Labour dystocia and mal presentations
1617

Chapter 8:
Third stage of labour
8.1 Normal third stage of labour ……………………………………………………………………..165
8.1.1 Description ………………………………………………………………………………………165
8.1.2 Routine prevention of postpartum haemorrhage ………………………………….165
8.1.3 Monitoring ………………………………………………………………………………………166
8.1.4 Examination of the placenta ………………………………………………………………167
8.2 Early postpartum haemorrhage …………………………………………………………………168
8.2.1 Possible causes …………………………………………………………………………………168
8.2.2 Management during the first 30 minutes …………………………………………….168
8.2.3 Cause-specific management ………………………………………………………………169
8.2.4 Management of persistent haemorrhage …………………………………………….170
8.3 Late postpartum haemorrhage ………………………………………………………………….172
8.3.1 Diagnosis …………………………………………………………………………………………172
8.3.2 Possible causes …………………………………………………………………………………172
8.3.3 Management ……………………………………………………………………………………172
8.4 Uterine inversion ……………………………………………………………………………………..173
8.4.1 Diagnosis …………………………………………………………………………………………173
8.4.2 Management ……………………………………………………………………………………173
8.5 Cervical and vaginal tears …………………………………………………………………………176
8.5.1 Diagnosis …………………………………………………………………………………………176
8.5.2 Management ……………………………………………………………………………………1768

8.1 Normal third stage of labour
The third stage of labour refers to the period that starts immediately after delive ry of the
newborn and ends with the completed delivery of the placenta and its attached
membranes.
There is a significant risk of haemorrhage during this stage of labour. All patients require
close monitoring and active prevention of haemorrhage, whether or not there are risk
factors.
8.1.1 Description
The third stage usual ly lasts 5 to 15 mi nutes.
–After the newborn is delivered, there is a rest period without contractions that lasts, on
average, 10 minutes. Use this time to take care of the newborn. Watch the mother
carefully, however, for signs of haemorrhage, which can occur at any time.
– Then, contractions resume, the placenta separates spontaneously. On abdominal
palpation the uterine fundus can be felt ascending and then descending again,corresponding to the migration/descent of the placenta. When the entire placenta hasreached the vagina, the uterus retracts and forms a hard ball above the pubic bone.
– The blood loss accompanying delivery of the placenta should not exceed 500 ml.
8.1.2 Routine prevention of postpartum haemorrhage
Active management of third stage of labour1
Active manageme nt of third stage of labour consists in the administration of oxytocin before
placental expulsion, followed by controlled cord traction then uterine massage to help
retraction of the uterus.
Administration of oxytocin immediately after the birth (or after the birth of the last infant in
a multiple pregnancy) AND before delivery of the placenta accelerates separation of the
placenta, faci litates its del ivery and he lps prevent postpartum haemorrhage .
Immediately after the birth of the infant, palpate the mother's abdomen to be sure she is
not carrying twi ns, then admi nister oxytocinslow IV or IM: 5 or 10 IU.
Then after clamping and cutting the cord, deliver the placenta with controlled cord traction
(during a contraction with counter pressure to the uterus, with a hand placed on theabdomen).
When oxytocin is used prior to delivery of the placenta, there is in theory, and especially if
the injection is not done immediately (i.e. within 3 minutes), a risk of retained placenta. Forthis reason, the birth attendant who administers oxytocin immediately after delivery of theinfant must be able to perform manual removal of the placenta, should it be necessary. Ifthese conditions are not met, oxytocin should be administered after placental expulsion.Third stage of l abour
1658

Use of oxytocin after delivery of the placenta
If oxytocin has not been given prior to placenta delivery, it should be administered after the
placenta has been completely delivered. This is less effective in preventing postpartum
haemorrhage, however.
oxytocinslow IV or IM: 5 or 10 IU
Uterine exploration to remove any placental fragments will be more difficult after injecting
oxytocin. Be sure that the placenta is complete before administering oxytocin.
In addition, massage the uterus to help uteri ne retraction.
8.1.3 Monitoring
–The birth attendant should che ck:
• The heart rate and blood pressure, and the amount of vaginal bleeding, while waiting
for the placenta to deliver. Monitoring should be maintained after expulsion of the
placenta (every 15 minutes for the first hour, then every 30 minutes for the next hour)
as the risk of hae morrhage persists.
• The length of the rest period: in the absence of haemorrhage, a maximum delay of
30to 45 minute s is tolerated for the expulsion of the placenta. Afte r that, the placenta
should be removed manual ly (Chapter 9, Se ction 9.2).
•That the uterus retracts and remains retracte d.
•That the entire placenta has been expel led.
– Uncontrolle d traction on the cord (i.e., done without a contraction or counterpre ssure) is
contra-indicated, as it can cause tearing of the placenta and, afterwards, retention of
placental fragments (with the attendant risk of haemorrhage and i nfection).
– Abdominal palpation can be used to determine whether the placenta has separated, by
pressing down on the abdomen just above the pubic bone . If the cord does not retract
when pressure is appl ied, the placenta has separated (Figure 8.1).
Figure 8.1
Placental separation has occurred if the cord fai ls to retract with abdomi nal pressure
–To facilitate expulsion from the vagina if it seems to be going slowly after the separation,
apply moderate pressure to the uterine fundus, directed toward the vagi na.!
Chapter 8
166

8.1.4 Examination of the placenta
Always examine the placenta to verify that it has been completely expelled. The uterus can
only retract properly if it is empty. Sooner or later, retained debris will lead to haemorrhage
or infection.
Examination of the membranous sac
Straighten the sac by inserting a hand into it, looking for a vessel that ends abruptly—
indicating that there might be a succenturiate lobe remaining in the uterus—or for a tear
pointing to retained membrane. In these cases, manual uterine exploration may be required
(Chapter 9, Section 9.3).
Examination of the maternal surface of the placenta
Regular, bright red cotyle dons. Any holes, roughene d or depressed areas, or any deep cuts
that fail to line up when the cotyledons are brought together may suggest retained
placenta, re quiring uterine expl oration for re moval.Third stage of l abour
1678

8.2 Early postpartum haemorrhage
Early postpartum haemorrhage is define d as bleeding that occurs within 24 hours (usually
immediately) after delivery of the placenta. The volume exceeds the normal 500 ml third
stage blood loss.
Delay in treatment can lead to coagulation disorders, with a risk of massive, diffuse
bleeding. Close delivery room monitoring is crucial for two hours postpartum , in order to
rapidly identify and treat hae morrhage.
8.2.1 Possible causes
Uterine atony
The placenta has been expelled, but the uterus fails to retract. The uterus gets larger,
extends, and becomes soft. Predisposing factors for uterine atony incude: overstretching,
(polyhydramnios, multiple pregnancy, large foetus), prolonged labour, and infection (chorio-
amniotitis).
Obstetric trauma
Uterine rupture; cervical, vaginal and vulvar lacerations; episiotomy that is bleeding, uterine
inversion.
Retained placenta
The entire placenta or a fragment of the pl acenta remains in the uterus.
In rare cases, it is impossible to remove the place nta manually because there is no cleavage
plane betwe en the placenta and the uterine wall (place nta accreta). In this event, refer for
hysterectomy.
Coagulation disorders
Coagulation disorders may be the cause or the result of hae morrhage.
For diagnosis, see Chapter 3, Section 3.2.2.
8.2.2 Management during the first 30 minutes
Treatment is always the same, and performed i mmediately to avoid massive haemorrhage:
–Ask for hel p.
– Evaluate the heart rate, blood pressure, level of consciousness, oxygen saturation (if
available), and blood loss (blood loss is easily underestimated, up to 50%), then monitor
regularly.
–Insert two IV lines (catheter 16-18G), rapid fluid resuscitation with Ringer lactate or 0.9%
sodium chl oride (1 litre over 15 mi nutes).
– In anticipation of a blood transfusion, determine the patient’s blood type and select
potential donors or make sure that blood is available. If transfusion is performed, the
blood must have been tested (HIV-1, HIV-2, hepati tis B, hepati tis C and syphi lis).
–Measure haemogl obin (HemoCue).
– High-flow oxygen therapy.Chapter 8
168

–If systolic blood pressure is < 90 mmHg, elevate the legs (keep, or replace, the patient's
feet in the de livery table sti rrups).
– Pe rform uterine massage to expel any clots and aid uterine contraction. In case of massive
haemorrhage, maintain bimanual compression unti l uterotonics take effect.
– Mak e sure the uterus is empty: immediately remove the placenta manually if it has not
yet delivered and/or manual ly explore the ute rus.
– Administe r routinely a uterotonic to correct ute rine atony or e nsure uterine retraction:
oxytocin : 5 to 10 IU by slow IV injection, and at the same time, start an IV infusion with
20IU of oxytocin in 1 litre of Ringer lactate or 0.9% sodium chloride, to be administered
over 2 hours (160 drops/mi nute).
–Insert a Fol ey catheter: ke eping bladde r empty faci litates uteri ne retraction.
– Inspect systematically the birth canal: check for injury to the cervix or vagina using
retractors.
–Record in a chart: results of the initial evaluation, monitoring and actions, indicating the
times.
8.2.3 Cause-specific management
Uterine atony
– Administer oxytocin: 5 to 10 IU by slow IV injection, and at the same time, start an IV
infusion with 20 IU oxytocin in 1 litre of Ringer lactate or 0.9% sodium chloride,
administere d over 2 hours (160 drops/mi nute).
– Combine with ute rine massage; mai ntain bimanual compression if bl eeding is severe.
–If no effect wi thin 15 mi nutes:
misoprostol sublingually: 800 micrograms2and/or methylergometrine IM: 0.2 mg
– If no effect, insert a balloon for uterine tamponade (Appendix 2).
Obstetric trauma (che ck routinely)
– Uterine rupture: Chapter 3, Se ction 3.3.
– Cervical or vagi nal tears: Section 8.5.
–An episiotomy can bleed: temporarily stop arterial bleeding with a clamp and suture as
quickly as possi ble.
– Uterine i nversion: Section 8.4.
Retained placenta
– Immediate manual removal if the placenta has not yet delivered and/or routine uterine
exploration to remove any clots or placental debris (allows good uterine retraction) and
to verify that there was no uterine rupture (for vaginal deliveries with a scarred uterus, in
particular).
–Perform manual placenta removal and manual uterine exploration under anaesthesia. Do
not proceed without anaesthesia unless anaesthesia cannot be performed i mmediately.
– Give routine anti biotic prophyl axis (cefazolin or ampicillin slow IVa: 2 g as a si ngle dose).
aFor patients with a history of immediate hypersensitivity reaction to penicillin (urticaria, respiratory
problems or oedema): clindamycin IV, 900 mg as a si ngle dose.Third stage of l abour
1698

Coagulation disorders
– Active management of the haemorrhage reduces the risk of secondary coagulation
disorders.
–In the event of coagul ation disorders, transfuse :
• fre sh whole blood (blood freshly collected, for less than 4 hours, and that has not been
refrigerated), or
•packed red blood ce lls or whole blood + fresh frozen pl asma.
8.2.4 Management of persistent haemorrhage
– Maintain adequate haemodynamics: Ringe r lactate up to 2 litres, then a plasma substitute
and blood. The goals are systolic blood pressure ≥ 100 mmHg, oxygen saturation ≥ 95%,
urine ouput ≥ 30 ml /hour, and normal l evel of consci ousness.
– Inse rt a Bakri intrauterine balloon (Appendix 2). If the patie nt is still in a BEmONC facility,
it is imperative to transfer her to a CEmONC faci lity once the bal loon is inserted.
–Transfuse if blood loss is heavy (> 1500 ml), to achieve or maintain a haemoglobin level of
at least 7 g/dl and/or if there are coagulation disorders. Blood or blood products must
have been scre ened before transfusion (HIV-1, HIV-2, hepati tis B, hepati tis C and syphi lis).
In the event of moderate haemorrhage with no coagulation disorder, transfuse packed
red blood cel ls or whol e blood.
In the event of massive haemorrhage and/or coagulation disorders, transfuse fresh whole
blood or packed red blood ce lls or whole blood + fresh frozen pl asma.
– Make sure that all procedure s (manual place nta removal, uterine exploration, birth canal
inspection, oxytocics, and urinary catheteri sation) have i ndeed been performe d.
– Additional me asures:
•at a minimum, massage the uterus every 15 minutes for 2 hours,
plus, if needed, one of the fol lowing procedure s:
• apply pressure to the abdominal aorta (just above the umbilicus) until the femoral
pulse is no longer palpable, for example, the time it take s to insert a Bakri balloon or
start laparotomy (Figure 8.2);
•compress the uterus with both hands through the abdominal wall, if it is still large and
atonic;
• compress the uterus between fingers in the vagina and a hand on the abdomen (Figure 8.3);
•compress the uterus be tween the fist and a hand on the abdomen (Fi gure 8.4).
Figure 8.2
Aortic compressi on!
Chapter 8
170

Figure 8.3
Uterine compression through the vagina
Figure 8.4
Uterine compression through the vagina
–Arrange transfer to a CEmONC facility for surgery if the situation is not controlled and for
those who have required a Bakri balloon.
–Further surgical procedures might be:
• Conservative:
– Stepwise ligation of the uterine blood supply (round ligaments, utero-ovarian
arteries, uterine arteries);
– Uterine compression suture (B-Lynch or other type suture)b.
• Radical: hysterectomy with adnexal preservation. Subtotal hysterectomy is preferable,
as it limits the operative time.
Note: after the acute episode, administer ferrous sulfate + folic acid PO for 3 months
(Chapter 4, Section 4.1).
bFor more information on B-Lynch suture, see: A Comprehensive Textbook of Postpartum Hemorrhage
2ndEdition. Section 9, Chapter 51: Therapy for Non-atonic Bleeding, C. B-Lynch and H. Shah. Conservative
Surgical Management.
http://www.glowm.com/pdf/PPH_2nd_edn_Chap-51.pdf!
!
Third stage of l abour
1718

8.3 Late postpartum haemorrhage
Excessive vagi nal bleeding from 24 hours to 6 weeks postpartum.
8.3.1 Diagnosis
A combination of the following signs: foul-smelling vaginal bleeding, fever, a uterus that is soft
and larger than expected, general deterioration, anaemia.
8.3.2 Possible causes
– Retaine d placenta or blood clots with secondary i nfection (endome tritis).
– Rarely, persistent trophoblastic disease or choriocarcinoma.
8.3.3 Management
– Admit to i npatient department.
– Administer immediately:
amoxicillin/clavulanic acid IV (dose expressed in amoxicillin): 3 g/day divided into 3
injections admi nistere d 8 hours apart
+ gentamicin IM: 3 to 5 mg/kg once dai ly
Continue this treatme nt for 48 hours (until fever disappears), then change to amoxicillin/
clavulanic acid PO (dose expressed in amoxicillin): 3 g/day in 2 to 3 divided dosescto
complete 5 days of treatment
or
ampicillin IV: 6 g/day di vide d into 3 injections admi nistered 8 hours apart
+ metronidazole IV: 1.5 g/day di vided into 3 i njections admi nistere d 8 hours apart
+ gentamicin IM: 3 to 5 mg/kg once dai ly
Continue this treatment for 48 hours (until fever disappears), then change to amoxicillin PO:
3 g/day in 3 divided doses + metronidazole PO: 1.5 g/day in 3 divided doses, to complete
5days of tre atment.
– Manually explore the uterus when cervical dilation permits, otherwise perform digital
curettage (Chapter 9, Section 9.4) or instrumental curettage with the widest curette
available (Chapter 9, Section 9.6) and administer a uterotonic agent (oxytocin IM or slow IV:
5 to 10 UI, or, if not available, methylergometrine IM: 0.2 mg or misoprostol sublingually:
800 micrograms).
cThe daily dose should be given in 2 divided doses if using the 8:1 or 7:1 formulation, and in 3 divided doses
if using the 4:1 formulation.Chapter 8
172

8.4 Uterine inversion
Uterus turns inside-out, typically as the placenta is delivered. Usually due to uterine atony
(grand multiparity) or sudden, forceful traction on the cord.
8.4.1 Diagnosis
– Usually, intense pelvic pain with feeling of “something coming down” and haemorrhage
of variable severity, quickly followed by vagal and hypovolaemic shock.
– Uterine fundus not apparent on abdominal palpation, protrudes into the vagina, or
protrudes from the vaginal opening (Figures 8.5 and 8.6).
8.4.2 Management
– Treat the shock and the haemorrhage immediately: Ringer lactate or 0.9% sodium
chloride; blood transfusion if immediately life-threatening. Use blood that has been
screened (HIV-1, HIV-2, hepatitis B, hepatitis C and syphilis).
– Trendelenburg position (dorsal decubitus, head down).
– Insert a Foley catheter and monitor urine output.
– Perform general anaesthesia if possible.
– If uterotonic treatment is in progress, stop it long enough to reduce the inversion.
– Swab the perineum with 10% polyvidone iodine.
– If the placenta has not detached, do not perform manual removal until after reducing the
inversion.
– While compressing the uterus, push it gradually back through the cervix with one hand
(Figures 8.7), toward the umbilicus, to return it to its normal position. Use the other hand,
placed on the abdomen, to hold the uterus in place.
– If necessary, explore the uterus (gently, to avoid recurrence) in order to remove any clots.
– Routine antibiotic prophylaxis ( cefazolin or ampicillin slow IVd: 2 g as a single dose).
– Resume or start uterotonic treatment: oxytocin slow IV or IM: 5 or 10 IU (or, if not
available, methylergometrine IM: 0.2 mg or misoprostol sublingually: 800 micrograms).
If manual reduction of the uterus fails, consider abdominal surgery: reduction of the
inversion with possible section of the retracted oedematous cervix, or even delayed
hysterectomy after necrosis develops.
dFor patients with a history of immediate hypersensitivity reaction to penicillin (urticaria, respiratory
problems or oedema): clindamycin IV, 900 mg as a single dose.Third stage of labour
1738Updated: June 2017

Figure 8.5
The inverted uterus does not reach the vaginal opening
Figure 8.6
The uterus is totally inverted and protrudes through the vaginal opening!
!
Chapter 8
174

Figures 8.7
Manual reduction of the inverted uterus!
Third stage of l abour
1758

8.5 Cervical and vaginal tears
Tears occur during delivery, and are more common in cases of cervical oedema, large
foetus, or instrumental extraction (forceps or vacuum extractor).
A special sterile set containing vaginal retractors and long instruments should be available in
every maternity ward for exploration and treatment of deep cervical and vaginal tears.
8.5.1 Diagnosis
Suspect a tear in cases of postpartum haemorrhage where there is good uterine retraction
and uterine rupture has been ruled out.
The source of the bleeding is discovered during inspection of the birth canal, with careful
examination of the vagina and cervix using two vaginal retractors.
8.5.2 Management
– Insert an IV line (16-18G catheter) and administer Ringer lactate or 0.9% sodium chloride.
– If possible, perform general or spinal anaesthesia to get good exposure.
– An assistant is usually needed to present the tissues using retractors. Good lighting is essential.
– Swab the perineum with 10% polyvidone iodine.
– Gently pull the cervix toward the outside using atraumatic forceps (ring forceps, for example)
and assess the extent of the tears.
• Small cervical tear, minimal bleeding: should heal spontaneously with no suturing and
without complications.
• On rare occasions, the cervical tear bleeds heavily and requires a few Dec3 (2-0)
absorbable figure-of-eight sutures in a single layer. Place the initial suture above the
apex of laceration to control retracted arteries (Figure 8.8).
• The vaginal walls should also be sutured in the event of a bleeding laceration. For
multiple vaginal lacerations with friable tissue that tears on suturing, insert a vaginal
pack and remove after 24 hours. Insert a Foley catheter while the pack is in place.
• If the tear extends up to the uterus (lower segment), transfer the patient to a surgical
setting for laparotomy.
Figure 8.8
Cervical tear !
Chapter 8
176Updated: June 2017

References
1International Confederation of Midwives and International Federation of Gynaecologists
and Obstetricians . Joint Statement Management of the Third Stage of Labour to Prevent
Post-partum Haemorrhage. 2003.
http://www.pphprevention.org/files/ICM_FIGO_Joint_Statement.pdf
2WHO recommendations for the prevention and treatment of postpartum haemorrhage.
Word Health Organization. Geneva, 2012.
http://apps.who.int/iris/bitstream/10665/75411/1/9789241548502_eng.pdfThird stage of l abour
1778

Chapter 9:
Intrauterine procedures
9.1 Precautions required for intrauterine procedures ……………………………………….181
9.1.1 Precautions common to all intrauterine procedures ………………………………181
9.1.2 Specific precautions for manual procedures …………………………………………181
9.2 Manual removal of the placenta ………………………………………………………………..182
9.2.1 Indications ……………………………………………………………………………………….182
9.2.2 Technique ………………………………………………………………………………………..182
9.3 Uterine exploration ………………………………………………………………………………….183
9.3.1 Indications ……………………………………………………………………………………….183
9.3.2 Technique ………………………………………………………………………………………..183
9.4 Digital curettage ………………………………………………………………………………………184
9.4.1 Indications ……………………………………………………………………………………….184
9.4.2 Technique ………………………………………………………………………………………..184
9.5 Manual vacuum aspiration (MVA) ……………………………………………………………..185
9.5.1 Indications ……………………………………………………………………………………….185
9.5.2 Contra-indications …………………………………………………………………………….185
9.5.3 Equipment ……………………………………………………………………………………….185
9.5.4 Technique ………………………………………………………………………………………..186
9.5.5 Patient follow-up ………………………………………………………………………………188
9.5.6 Complications …………………………………………………………………………………..188
9.6 Instrumental curettage …………………………………………………………………………….189
9.6.1 Indications ……………………………………………………………………………………….189
9.6.2 Precautions ………………………………………………………………………………………189
9.6.3 Equipment ……………………………………………………………………………………….189
9.6.4 Technique ………………………………………………………………………………………..189
9.6.5 Patient follow-up ………………………………………………………………………………191
9.6.6 Complications …………………………………………………………………………………..191
9.7 Embryotomy ……………………………………………………………………………………………193
9.7.1 General conditions and precautions …………………………………………………….193
9.7.2 Contra-indications …………………………………………………………………………….194
9.7.3 Equipment ……………………………………………………………………………………….194
9.7.4 Craniotomy for cephalic presentation with entrapment …………………………195
9.7.5 Cranioclasis ……………………………………………………………………………………..196
9.7.6 Craniotomy for retention of the aftercoming head (breech) ……………………196
9.7.7 Decapitation for transverse lie ……………………………………………………………1979

9.1 Precautions required for intrauterine procedures
There are two types of i ntrauterine proce dures:
– Manual: manual removal of the placenta, uterine exploration, and digital curettage;
– Instrumental: manual vacuum aspiration (MVA), instrumental curettage, and embryotomy.
9.1.1 Precautions common to all intrauterine procedures
Bladder emptying
This facilitates the procedure and reduces the risk of bladder i njury.
–Have the patient urinate on her own.
–Insert a steri le urinary catheter only if the patient does not urinate on her own.
Asepsis
– Cleanse the vulva and perineum with the polyvidone iodine scrub (or, if unavailable,
ordinary soap). Rinse and dry. Then, swab the vulva and perineum with 10% polyvidone
iodine sol ution.
– Use sterile drapes, sterile compresses and sterile gloves (sterile uterine exploration
gloves, with long cuffs, for manual procedure s).
Anaesthesia
All procedure s should be performed under anaesthesia. A proce dure may be done without
anaesthesia on two conditions: it is a life-threatening emergency (e.g. postpartum
haemorrhage due to retained placenta) and anaesthe sia cannot be done i mmediately.
For manual vacuum aspiration, a combination of premedication and local anaesthetic
(paracervical block) provides ade quate anaesthesia.
Protection of personnel
All intrauterin e procedures expos e the practition er to the risk of HIV infection. Protective
clothing is e ssential: gloves, gown, rubber apron, mask, protecti ve eyewear.
9.1.2 Specific precautions for manual procedures
For all manual i ntrauterine procedures, add:
– Antibiotic prophylaxis before the procedure:
cefazolin or ampicillin slow IVa: 2 g as a si ngle dose
AND
–A uterotonic agent (right after the procedure) to improve uterine retracti on:
oxytocinIM or slow IV: 5 to 10 IU as a single dose (or, if unavailable, methylergometrine IM:
0.2 mg)
aFor patients with a history of immediate hypersensitivity reaction to penicillin (urticaria, respiratory
problems or oedema): clindamycin IV, 900 mg as a si ngle dose.Intrauterine procedure s
1819

9.2 Manual removal of the placenta
9.2.1 Indications
– Placenta not yet expel led 30 to 45 minutes after de livery.
–Haemorrhage prior to spontaneous e xpulsion of the pl acenta.
9.2.2 Technique
(Figure 9.1)
– Follow precautions common to all intrauterine procedures (Section 9.1.1) and specific
precautions for manual procedures (Section 9.1.2).
–Cup the fundus with one hand and hold it down.
– Advance the other hand, fully pronated, directly to the fundus and locate the cleavage
plane betwe en the uterine wall and the placenta with the fingertips. This hand is inserted
all the way up to the forearm in the ge nital tract.
–Once the cleavage plane has been located, use the side of the pronated hand like a spoon
to detach the placenta and bring it out.
– Immediately rei nsert the hand to perform uterine expl oration.
On very rare occasions, it is impossible to remove the placenta manually because there is no
cleavage plane betwee n the place nta and the uterine wall (placenta accreta). In this event,
refer for hyste rectomy.
Figure 9.1
Manual removal of pl acenta!
Chapter 9
182

9.3 Uterine exploration
Manual exploration of the uterine cavity to verify the integrity of the uterus and remove any
placental debris or blood clots i nterfering with retraction and, hence, haemostasi s.
9.3.1 Indications
– Suspe cted uteri ne rupture.
– Suspe cted retai ned products after e xamination of expel led placenta.
–Postpartum haemorrhage wi thin 24 hours of de livery.
– Routinely after manual re moval of the pl acenta.
Note: in the event of postpartum haemorrhage, rule out vaginal or cervical tear, especially if
the placenta appears compl ete and the uterus is wel l-contracte d (Chapte r 8, Section 8.5).
9.3.2 Technique
– Follow precautions common to all intrauterine procedures (Section 9.1.1) and specific
precautions for manual procedures (Section 9.1.2).
– Systematic uterine exploration: two faces, two sides, one fundus, two horns. Use the
finge rs to search for pl acental de bris and remove by hand.
–Ensure uterine retraction using abdominal massage: when the uterus retracts it resembles
a firm bal l.Intrauterine procedure s
1839

9.4 Digital curettage
Use of finger(s) to remove placental fragme nts or blood clots dete cted late after an abortion
or delivery, when insufficient cervical dilation renders uterine exploration impossible (the
cervix must however be suffi ciently open to al low insertion of one fi nger, two if possi ble).
9.4.1 Indications
– Delayed detection of haemorrhagic abortion or retained placenta, where uterine
exploration cannot be performe d.
9.4.2 Technique
(Figure 9.2)
– Follow precautions common to all intrauterine procedures (Section 9.1.1) and specific
precautions for manual procedures (Section 9.1.2).
– Inse rt the index finger, and the middle finge r if possible , into the uterine cavity; cup the
uterus through the abdomen with the other hand.
– Systematically e xplore and remove any re maining fragments.
Figure 9.2
Exploration of the uterus with two fi ngers!
Chapter 9
184

9.5 Manual vacuum aspiration (MVA)b
Evacuation of the ute rine contents using sucti on.
9.5.1 Indications
– Incomplete abortion be fore 12 to 14 weeks LMP.
– Molar pregnancy.
– Termination of pregnancy before 12 to 14 weeks LMP (see Chapter 12).
9.5.2 Contra-indications
Absolute
–Pregnancy (non molar) beyond 14 weeks LMP.
Relative
– Purule nt cervicitis and pel vic infection: start anti biotics before doing the procedure .
– Coagulation disorders: risk of haemorrhage. MVA must be performed in a facility where
emergency surgery and blood transfusion are available.
9.5.3 Equipment
–MVA set contai ning:
•2 Ipas MVA Plus® 60-ml syri nges
•2 bottles of si licone for l ubricating the syri nge
•20 sets of Ipas Easy Grip® fl exible cannulae (4, 5, 6, 7, 8, 9, 10, 12 mm) steri le, single use
•5 double-ended Hegar’s ute rine dilators (3-4, 5-6, 7-8, 9-10, 11-12 mm)
•1 Pozzi forceps
•1 Collin vaginal speculum
•1 probe
•1 Cheron dressing force ps
•1 100-ml gal ipot
•1 stainless stee l instrument basket
All the equipment is autoclavable , except the cannul ae, which are strictly single use.
–For the procedure:
•1 sterile drape for laying out the sterile equipment
•1 aperture drape to place over the patient’s vulva
• polyvidone iodine scrub solution or, if unavailable, ordinary soap•10% polyvidone iodine dermal solution• sterile compresses and gloves• absorptive pad to place under the patient’s buttocks
•1 bright light
bFor more information on MVA: Performing Uterine Evacuation with the Ipas MVA Plus®Aspirator and Ipas
EasyGrip®Cannulae: Instructional Booklet (second edition, 2007).
http://www.ipas.org/~/media/Files/Ipas%20Publications/UTEEVAC2E08.ashxIntrauterine procedure s
1859

– For local anaesthesia:
• long sterile needle (either 22G LP or 21G IM)
• 1% lidocaine (without epinephrine) + sterile syringe and needle
9.5.4 Technique
Follow precautions common to all intrauterine procedures (Section 9.1.1).
Preparing the patient
– If the patient has a purulent cervicitis or pelvic infection, start antibiotic therapy before
performing the aspiration (increased risk of uterine perforation). For antibiotic therapy,
see Section 9.6.6.
– If the cervix is firm and closed (i.e. molar pregnancy when the cervix is closed), administer
misoprostol sublingually or vaginally into the posterior fornix: 400 micrograms as a single
dose, at least 3 hours before the procedure1to open the cervix and prevent traumatic
cervical dilation.
– Oral premedication before paracervical block:
An hour before the procedure: diazepam PO, 10 mg
A half-hour before the procedure:
ibuprofen PO: 800 mg
+
codeine PO: 30 mg if < 60 kg; 60 mg if > 60 kg
or
tramadol PO: 50 mg if < 60 kg; 100 mg if > 60 kg
Note : in cases of incomplete abortion with heavy bleeding, the procedure cannot be
delayed. In such cases:
– Do not administer oral premedication;
– If the context permits (CEmONC facility), perform the procedure under general anaesthesia;
– If general anaesthesia is not possible, replace the oral premedication with:
diazepam IM: 10 mg (do not administer IV, as there is a risk of respiratory depression)
+tramadol SC: 50 mg if < 60 kg or 100 mg if > 60 kg before the paracervical block.
Preparing the equipment
– Prepare several cannulae of different sizes:
• As a rule of thumb, the cannula diameter should correspond roughly to the gestational
age in weeks LMP. For example, at 10 weeks LMP, choose a cannula that is 8 to 10 mm
in diameter.
• In practice, the diameter of the cannula inserted will depend on the dilation obtained.
For example, if at 10 weeks LMP it is only possible to easily dilate up to a No. 8 dilator,
use an 8-mm cannula.
Paracervical block
– Insert the speculum; disinfect the cervix and vagina with 10% polyvidone iodine solution.
– Place the Pozzi forceps on the anterior cervix at 12 o'clock and apply gentle traction to the
cervix in order to see the transition between the cervix and the vaginal wall. Injections for
the paracervical block are given in this transition zone.
Perform four injections, 2 to 3 ml of 1% lidocaine each, at four sites around the cervix
(2, 5, 8 and 11 o'clock sites), to a maximum depth of 2 to 3 mm; do not exceed 20 ml in
total.Chapter 9
186Updated: June 2017

Dilation
Dilate the cervix if the cervical canal cannot accommodate the cannula appropriate for
gestational age (or the size of the uterus). Di lation should be smooth and gradual :
– With one hand, pull the force ps attache d to the cervix and keep traction in order to bring
the cervix and the ute rine body into the best possi ble alignment.
– With the other hand, insert the smallest diamete r dilator; then switch to the next larger
dilator. Continue in this way, using the next size dilator each time, until obtaining dilation
appropriate to the cannula to be inserted, without ever relaxing the traction on the
cervix.
– Insert the dilator through the internal os. A resistance may be felt: this indicates that
there is no need to advance the dilator any further. This resistance is not necessarily felt.
In such case, it can be assumed that the internal os has been penetrated whe n the dilator
has been i nserted 5 cm beyond the e xternal os.
–Do not force the cervix with the dilators (risk of rupture or perforation, especially when
the uterus is very retro- or anteverte d).
Aspiration
–Attach the prepared (i.e. under vacuum) steri le syringe to the chosen cannul a.
– Maintain traction on the cervix with one hand.
– With the other hand, gently insert the cannula into the uterine cavity. Rotating the
cannula while applying gentle pressure facilitates insertion. Slowly and cautiously push
the cannula into the ute rine cavity unti l it touches the fundus.
– Release the valves on the syringe to perform the aspiration. The contents of the uterus
should be vi sible through the syringe (blood and the whi tish products of concepti on).
– Hold the syringe by the tube (not the plunge r) once a vacuum has been established in the
syringe and the cannula has been inserte d into the uterus; otherwise, the plunger can go
back in, pushing the aspirated tissue or air back into the uterus.
– Carefully (risk of perforation) suction all areas of the uterus, gently rotating the cannula
back and forth 180°. Take care not to break the vacuum by pulling the cannula out of the
uterine cavi ty.
–If the syringe is full, close the valves, disconnect the syringe from the cannula, empty the
contents, re-establish the vacuum, and reconnect the syringe to the cannula and continue
the procedure.
–Stop when the uterus is empty, as indicated by a foamy, reddish-pink aspirate, with no
tissue in the syringe. It is also possible to assess the emptiness of the uterus by passingthe cannula over the surface of the uterus: if the surface feels rough, or it feels as if the
uterus is contracting around the cannula, assume that the evacuation is complete.
– Close the valve, detach the syringe and then, remove the cannula and the forceps. Check
for bleeding before removing the speculum.
In a surgical setting, aspiration can be done using a cannula connected to the electric suctionmachine, with a maximum pressure of 800 mbar.
Examining the aspirated contents
To conf irm that the uteru s has been emptied , check the presen ce and quan tity of debris,
estimating whether it corresponds to the gestati onal age.
The debris consists of villi, foetal membranes and, beyond 9 weeks, foetal fragments. To
inspect the tissues vi sually, place them in a compress or strai ner, and rinse them with water.Intrauterine procedure s
1879

9.5.5 Patient follow-up
– No routine uterotoni c, except in the event of molar pre gnancy.
– After the procedure, bleeding continues without clots. Monitor vital signs and blood loss.
Settle the patient comfortably during the monitoring period (at least 2 hours).
– Pain is moderate, and relieved by paracetamol and/or ibuprofen.
– Verify and update tetanus immunization if unsafe abortion is suspected.–The patient can go home if the vital signs are stable, if she can walk, and she has been
given the following information:
•cramps will continue for a few days (prescribe an analgesic);• bleeding will last for 8 to 10 days;• menstrual periods will resume within 4 to 8 weeks;•she will be fertile again immediately (offer contraception, Chapter 11, Section 11.5);• advice on hygiene; no vaginal douches;• signs and symptoms for which she must be seen: prolonged bleeding (more than
2 weeks), bleeding heavier than normal menstrual periods, severe pain, fever, chills,
malaise, fainting;
• routine follow-up visit 10 to 15 days after the procedure (look for signs of infection,
incomple te evacuati on).
9.5.6 Complications
– Incomplete evacuation of the uterus due to cannula that is too small or to interrupted
suction: start over.
–Perforated ute rus, bleeding, pelvic infection: see Section 9.6.6.
– Air embolism: very rare; can occur whe n the plunger of the syringe is pushed while the
cannula is sti ll inside the uterine cavity.
– Haematometra: in the hours following the procedure , retention of blood in the uterine
cavity. The uterus become s diste nded and extremely sensitive. Treat by re-evacuating the
uterus, administering an oxytocic agent and massaging the uterus.Chapter 9
188

9.6 Instrumental curettage
Removal of placental fragments after incomplete abortion, or incomplete delivery of the
placenta, using an instrument (curette).
9.6.1 Indications
– Retained placenta or blood clots after incomplete abortion:
Curettage is not the method of choice. It is only used if:
• Before 12-14 weeks LMP: MVA is not available or is not effective;
• After 12-14 weeks LMP: the cervix is not dilated enough naturally to perform digital
curettage.
– Retained placenta or blood clots after childbirth:
• Immediately after delivery, it is always possible to perform uterine exploration or digital
curettage; there is no reason to perform instrumental curettage.
• Even some time after delivery, instrumental curettage is used only in exceptional
circumstances—when the cervix is not dilated enough naturally to allow uterine
exploration or digital curettage.
9.6.2 Precautions
– This procedure should be performed in a CEmONC facility.
9.6.3 Equipment
– Curettage set containing:
• 1 set of 3 blunt-edge curettes
• 1 DeBakey tissue forceps
• 2 vaginal retractors
• 8 Hegar’s uterine dilators (4, 6, 8, 10, 12, 14, 16, 18 mm)
• 1 Pozzi forceps• 1 Collin vaginal speculum• 1 uterine sound
• 1 Cheron dressing forceps• 1 100-ml galipot
• 1 stainless steel instrument basket
9.6.4 Technique
Follow precautions common to all intrauterine procedures (Section 9.1.1).
Preparing the patient
– If the patient has a purulent cervicitis or pelvic infection, start antibiotic therapy before
performing the curettage (increased risk of uterine perforation). For antibiotic therapy,
see Section 9.6.6.Intrauterine procedures
1899

–In cases of incomplete second trimeste r abortion or after childbirth: antibiotic prophylaxis
(cefazolin or ampicillin slow IVc: 2 g as a si ngle dose).
– Cervix preparation: as for manual vacuum aspiration (Section 9.5.4).
General or spinal anaesthesia
If unavailable, use premedication + paracervical block, as for manual vacuum aspiration
(Section 9.5.4).
Dilation
As for manual vacuum aspi ration (Section 9.5.4).
Curettage
(Figure 9.3)
– With one hand, pull the Pozzi forceps attached to the cervix and keep traction in order to
bring the cervix and the uterine body into the best possible alignment.
–Choose the largest possible curette, since the smaller the curette, the greater the risk of
trauma. The limit is the degree of dilation obtained with the dilators.
– The sound can be used, but it is not compulsory. The depth of the uterus can also be
assessed by gently advancing the curette to the uterine fundus and noting the length.
– Explore from the fundus down toward the cervix, in order to bring the debris outward,
avoiding perforation. Hold the curette lightly between the thumb and index finger, with
the handle resting against the tips of the other fingers, thus allowing an oscillatorymotion. Do not grasp the curette with the entire hand.The goal is to detach the fragments without abrading the mucous membranes. Do not
necessarily expect the gritty sensation felt through the curette when curettage is too
deep.When the proce dure is finished, verify that the uterus is empty: no more tissue come s out
with the curette. The re is a rough fe eling as it passes over the e ntire uterine surface.
Figure 9.3
Curettage
cIn patients with a history of immediate hypersensitivity reaction to penicillin (urticaria, respiratory problems
or oedema): clindamycin IV, 900 mg as a si ngle dose.!
Chapter 9
190

9.6.5 Patient follow-up
After abortion
Same follow-up and advi ce as after manual vacuum aspi ration (Section 9.5.5).
After childbirth
– Routinely admi niste r oxytocin IM or slow IV: 5 or 10 IU.
9.6.6 Complications
Persistent bleeding
– Incomplete e vacuation of the uterus: start over.
– Uterine atony: administer a uterotonic (Chapter 8, Section 8.2.3).
– Vaginal or cervical lacerations (common with unsafe abortions).
Perforation of the uterus
– Perforation by di lators or curettes: bl eeding, instrume nt goes in too far, pai n.
– Possible bladder injury and, potentially, subseque nt fistula if the bladder was not emptied
prior to curettage. If this happens, place a urinary cathete r immediately and leave in place
for 7 days; this usual ly allows the bl adde r to heal.
The treatment is rest plus anti biotics:
amoxicillin/clavulanic acid PO: 3 g/day in 2 or 3 di vided dose sdfor 5 days
or
amoxicillin PO: 3 g/day in 3 divide d doses + metronidazole PO: 1.5 g/day in 3 divided doses
for 5 days
In case of i nfection, treat for 10 days.
If the patient is in a BEmONC facility, refer her to a CEmONC facility.
Monitor for peritoneal signs (pain or guarding) in the following days. Appearance of these
signs necessitates laparotomy for investigation of possible lesions of the abdominal organs.
Infections
– End ometritis, salpin gitis, pelvic periton itis, and septicaemia must be preven ted by strict
asepsis, non-traumatic procedures and prophylactic antibiotics in post-childbirth and
second trimester abortion ( Section 9.1.2) cases.
–In a febrile patient with active pel vic infection, start anti biotic therapy:
amoxicillin/clavulanic acid IV: 3 g/day in 3 divided doses + gentamicin IM: 3 to 5 mg/kg
once daily
or
ampicillin IV: 6 g/day in 3 di vided doses
+ metronidazole IV: 1.5 g/day in 3 di vided doses
+ gentamicin IM: 3 to 5 mg/kg once dai ly
dThe daily dose should be given in 2 divided doses if using the 8:1 or 7:1 formulation, and in 3 divided doses
if using the 4:1 formulation.Intrauterine procedure s
1919

Continue this treatment for 48 hours (unti l fever disappears), then change to:
amoxicillin/clavulanic acid PO: 3 g/day in 2 or 3 divided doseseto complete 5 days of
treatment
or
amoxicillin PO: 3 g/day in 3 divided doses + metronidazole PO: 1.5 g/day in 3 divide d doses
to complete 5 days of treatment
In case of perforation, treat for 10 days.
eThe daily dose should be given in 2 divided doses if using the 8:1 or 7:1 formulation, and in 3 divided doses
if using the 4:1 formulation.Chapter 9
192

9.7 Embryotomyf
Destructive procedure to reduce the volume of a dead foetus to facilitate vaginal delivery
when obstruction prevents this from occurring natural ly.
This procedure, often performed on a fragile and infected uterus, carrie s the risk of trauma
(e.g., uterine rupture, cervical or vaginal injury, and damage to maternal soft tissue with
fistula). This risk is e specially high in case of decapi tation.
Few people have experience with these procedures. The operators must have the
knowledge of obstetrics, must feel comfortable performing obstetric manoe uvres and must
have skills to manage potenti al complications.
Some practitioners would rathe r perform a caesare an section on a dead foetus than have to
mutilate a foetus. However, independently of the mode of delivery (by caesarean section or
vaginally), obstructed labour carries a significant risk of puerperal infection, fistula and
postpartum haemorrhage . In addition, caesarean section can place the mother at significant
risk in terms of both survival and function. The objective of embryotomy is to reduce such
risks.
Embryotomy should be performed in a CEmONC facility (refer if necessary, even if the
referral takes ti me).
9.7.1 General conditions and precautions
There is no urgency in extracting the foetus. The priority is maternal intensive care
(intrave nous line, IV hydration, antibiotic therapy for prolonge d rupture of membrane s or
infection, and urinary cathete risation).
The embryotomy can be performed once the mother is stable, under the following
conditions:
– Confirm foetal death: no heart tone on foetal Doppler or ul trasound.
– Confirm the obstacle to vagi nal delivery due to si ze and/or pre sentation.
– Mak e sure there is adequate acce ss to the foetus: full or nearly full dilation (> 8 cm) and
ruptured me mbranes.
–Insert a Foley catheter.
– Perform the procedure in the operating room under strict aseptic conditions and
anaesthesia; always prepare for laparotomy in case uterine rupture.
–Take time to explain to the mother and family the expected benefits (avoiding caesarean
section) and potential complications (possible laparotomy if the embryotomy fails or the
uterus ruptures). Obtain the pati ent’s consent.
fFor more information on destructive delivery, see: Peter C. Bewes, James Cairns, Jim Thornton Maurice
King. Primary Surgery: Non-Trauma v.1. 1990 (last update: 2008).http://www.primary-surgery.org/ps/vol1/html/index.htmlIntrauterine procedure s
1939

– Afte r extracting the foetus, routi nely check:
•the uterine cavity (ute rine exploration with anti biotic prophyl axis, Section 9.3);
• the vaginal walls (use the vaginal retractors in the curettage set, for example, to get
adequate exposure ).
– Afte r the procedure, routi nely admi niste r oxytocin IM or slow IV: 5 IU or 10 IU.
– In case of prolonged labour with prolonged pressure from the foetus engaged in the
pelvis, leave the Foley catheter in place for 14 days to reduce the risk of fistula formation.
–Care for the body of the infant: suture the skin wounds; clean and wrap up the infant to
show/give him to the parents or family, depending on their choice.
9.7.2 Contra-indications
–Doubt about whe ther the foetus is dead
– Uterine rupture
– Dilation less than 8 cm
9.7.3 Equipment
– Smellie perforator (Figure 9.4)– Dubois scissors or large, curved scissors (Figure 9.5)–Braun cranioclast (Figure 9.6)–4 Faure forceps
Figure 9.4 Figure 9.5 Figure 9.6
Smellie perforator Dubois scissors Braun cranioclast
!
!
!
Chapter 9
194

9.7.4 Craniotomy for cephalic presentation with entrapment
Procedure in which the skull is puncture d to reduce the volume of the foetal head, which is
preventing del ivery.
Technique
(Figure 9.7)
– Have an assistant rest both palms on the head of the foetus and apply downward pressure
toward the pelvis.
– Insert one hand, shaped like a channel, into the vagina, in contact with the head of the
foetus.
– Using the other hand, slide the perforator along the channel formed by the first hand (to
protect the vagina) until it makes contact with the head of the foetus. This can be done
under direct vision after retraction with vaginal retractors.
– The perforation should be made in the centre of the skull to protect the mother's soft
tissues. It is easier to do it in a fontanelle. Rotate the instrument to make the perforation,
and then remove it so that the cerebrospinal fluid and/or brain matter can drain through
the hole.
– On ce the cerebrospin al fluid spills out, the head should collap se and delivery should be
easy; if not, apply traction to the skull with 3 or 4 forceps, gripping the scalp around the
perforation. If necessary, perform cranioclasis.
Note: if the foetus is hydrocephal ic, perforation can be replaced by nee dle aspiration.
Figure 9.7
Embryotomy with the Smel lie perforator!
Intrauterine procedure s
1959

9.7.5 Cranioclasis
Afte r craniotomy, gripping and crushing the bone s of the skull to reduce its bulk and allow
delivery.
Technique
– Insert the cranioclast’s solid jaw into the opening made by the perforator. Place the
hollow jaw against the skul l.
– Adjust the two jaws with the screw and extract the head in the most favourable
orientation.
9.7.6 Craniotomy for retention of the aftercoming head (breech)
Technique
(Figure 9.8)
– Have an assistant rest both palms on the head of the foetus and apply downward
pressure toward the pelvis.
– Pull the body of the foetus out and down to gain access to the occiput.
If necessary, retract the anterior vaginal wall using a vaginal wall retractor.
– Insert the perforator (or scissors, if there is no perforator) under the occiput. Rotate the
instrument to make the perforation. Open and close to cut up the contents.
– Remove the perforator and apply traction to the trunk. If the head remains trapped,
traction can be applied directly to the skull with forceps attached around the perforation.
Note: if the foetus is hydrocephalic, perforation can be replaced by needle aspiration.
Figure 9.8
Craniotomy for retention of the aftercoming head!
Chapter 9
196

9.7.7 Decapitation for transverse lie
Procedure in which the foetus is decapitated to rel ieve impaction due to a transve rse lie.
This is the most difficult type of embryotomy to perform, and the one carrying the greatest
risk of maternal trauma.
If the foetus is big and/or hard to access, embryotomy cannot be done and caesarean
section is the first and only option. Be aware that the caesarean section will be complicated,
with pote ntially difficult foetal extraction and the risk of e nlarge ment of the hysterotomy.
Embryotom y can be attempted if the foetus is small and easy to access. First try internal
version (Chapter 7, Section 7.8) in the operating room unde r anaesthesia and total breech
extraction (Chapter 6, Section 6.3), with or without crani otomy.
Technique
(Figure 9.9)
– Determine the exact position of the foetus (position of the head and neck and which arm
is prolapsed.
– In case of neglected shoulder presentation, have an assistant apply traction to the
prolapsed arm (do not try to section the arm first, as it can be used to pull the body
downward).
– Slide one hand behind the foetus and surround the neck with thumb and inde x finger, like
a necklace.
– With the other hand, slide the closed scissors into the channel formed by the first hand,
keeping them flat against the hand. It is i mperative to approach the ne ck at a right angl e.
– Using fingers to control and guide, section the neck bit by bit, in the hollow of the hand,
opening the scissor blades only sl ightly each ti me.
– Afte r decapitation, bring the arms down one after the other and del iver the body.
–To deliver the head, grasp the neck stump and pull downward, performing the delive ry as
for retention of the aftercoming head, fingers in the foe tus’ mouth.
Figure 9.9
Decapitation using sci ssors!
Intrauterine procedure s
1979

References
1World Health Organization. Safe abortion: technical and policy guidance for health
systems. Geneva, 2012.
http://www.who.int/reproductivehealth/publications/unsafe_abortion/9789241548434/en/Chapter 9
198

Chapter 10:
Newborn care in the maternity hospital
10.1 Routine care and examination in the first few hours of life …………………………201
10.1.1 Clearing the airway ………………………………………………………………………..201
10.1.2 Cord clamping and cord care ……………………………………………………………201
10.1.3 Apgar score …………………………………………………………………………………..201
10.1.4 Clinical examination ……………………………………………………………………….202
10.1.5 Thermoregulation …………………………………………………………………………..203
10.1.6 Feeding …………………………………………………………………………………………203
10.1.7 Preventive treatments …………………………………………………………………….203
10.1.8 Vaccinations ………………………………………………………………………………….204
10.1.9 Daily monitoring …………………………………………………………………………….204
10.2 Neonatal resuscitation …………………………………………………………………………….205
10.2.1 Basic resuscitation ………………………………………………………………………….205
10.2.2 After resuscitation ………………………………………………………………………….207
10.3 Care of the sick newborn ………………………………………………………………………….208
10.3.1 Danger signs ………………………………………………………………………………….208
10.3.2 Management of life-threatening emergencies …………………………………..208
10.3.3 Management of symptomatic neonatal infections ……………………………..209
10.3.4 Management of asymptomatic newborns at risk of neonatal infection …210
10.3.5 Management of hypoglycaemia ………………………………………………………211
10.3.6 Management of jaundice ………………………………………………………………..212
10.4 Specific care when the mother has a transmissible infection ……………………….214
10.4.1 Syphilis ………………………………………………………………………………………….214
10.4.2 Genital gonococcal and/or chlamydial infection …………………………………214
10.4.3 Genital herpes ……………………………………………………………………………….215
10.4.4 Hepatitis B infection ……………………………………………………………………….215
10.4.5 HIV infection ………………………………………………………………………………….215
10.4.6 Active pulmonary tuberculosis …………………………………………………………216
10.5 Care of the low birth weight newborn (1500-2500 g) ………………………………….217
10.5.1 Kangaroo care ……………………………………………………………………………….217
10.5.2 Thermoregulation …………………………………………………………………………..218
10.5.3 Feeding …………………………………………………………………………………………218
10.5.4 Monitoring ……………………………………………………………………………………218
10.6 Criteria for discharge from the maternity hospital ……………………………………..21910

10.1 Routine care and examination in the first few
hours of life
Immediately and rapidly asse ss the infant’ s condition so that resuscitation can be started, if
needed (Section 10.2). The resuscitation equipment should be ready at hand and ready for
use.
10.1.1 Clearing the airway
Wipe the nose and mouth to clear the ai rway.
Only suction the nose and mouth if there is obvious obstruction. Do not enter the
larynx/trachea (there is a risk of bradycardia or laryngeal spasm). Preferably use a suctionbulb (Penguin).
10.1.2 Cord clamping and cord care
Wait at least 2 minutes before clamping the cord in all infants who are crying vigorously
(and especially those wei ghing less than 2500 g).
For optimal transfusi on, keep the infant on the mothe r’s chest.
Clamp the cord with two Koche r forceps 10 cm from the umbilicus and cut betwee n the two
forceps. Use sterile blade or scissors – a different pair than were used for episiotomy, if
performed.
Tie off the cord with a Barr clamp or sterile thre ad (double ligature), leaving a 2- to 3-cm
stump.Disinfect the umbilicus with a sterile compress soaked in
7.1% chlorhexidine (or, if not
available, 10% polyvidone with a maximum of 3 appl ications total ).
10.1.3 Apgar score
The Apgar score is evaluate d at 1 and 5 minutes after comple te delivery of the infant and
recorded in the medical chart and the infant’s health record.
The score is a tool for monitoring the infant’s adaptation to extra-uterine life. It is not
used to determine whether resuscitation is indicated; this should be evaluated at birth,
based on whether or not there is spontaneous respiratory effort, without waiting for the
1-minute assessment.
In case of resuscitation, the Apgar score is determined retrospectively.
If the Apgar score is ≤ 4 at 1 minute or ≤ 6 at 5 minutes, the midwife should call the doctor
and should initiate necessary steps based on infant’s needs. Once stabilised, the infant
should be kept under observation for at least 24 hours.Newborn care in the mate rnity hospi tal
20110Updated: February 2017

Table 10.1 – Apgar score
*A healthy infant is usually born cyanotic but turns pink within 30 seconds after breathing starts. For infants
with dark ski n, assess skin colour by the soles of the fee t, palms of the hands and mucous me mbranes.
Table 10.2 – Significance of the Apgar score
10.1.4 Clinical examination
The birth attendant should perform a complete examination of the newborn as soon as
possible and preferably within 2 hours. The examination should be done unde r a warmer for
infants.
All observations are recorded on a moni toring sheet.
The first priority is to look for danger signs: e.g. abnormal temperature, abnormal colour,
difficulty breathing, neurological signs, severe abdominal distension, or symptomatic
hypoglycaemia ( Sections 10.3.1 and 10.3.5).
Assess the risk factors for neonatal infection (Section 10.3.4) for all infants, whether the
examination reveals danger signs or not.
The exami nation includes:
– Respiratory rate (normal values for infants 0-1 month are 30-60 breaths/mi nute)
–Heart rate (normal values for infants 0-1 month are 100-160 beats/mi nute)
– TemperatureItems
evaluated/score0 1 2
Skin colour* Extreme pallorCyanotic extre mities
No central cyanosisTotally pi nk
Respiration None Abnormal (sl ow,
shallow, apnoea, etc.)Normal
Heart rate 0 ≤ 100/minute > 100/minute
Muscle tone Absent Hypotony
Incomplete flexion ofextremitiesGoodComplete flexion ofextremities
Responsiveness(after stimulation) Nil Grimace Good, vigorous cry
1-minute score
0 – 4 Asphyxia
5 – 7 Difficulty adapti ng
8 – 10 Good adaptati on5-minute score
0 – 6 Asphyxia
7 – 8 Difficulty adapti ng
9 – 10 Good adaptati onChapter 10
202

– Weight (we igh the infant naked on an appropriate scal e, calibrate d beforehand).
– Examination of the skin and mucous membranes, oral cavity, palate, eyes, ears,
fontanelles, abdomen, spine, genital organs, anus, feet, hands; neurological examination
(posture, tone and refl exes, including sucki ng, grasp, response to sti mulation).
– Che ck if the infant urinates and produces stool s.
10.1.5 Thermoregulation
–At birth, dry the infant with a clean, dry cloth. Then, wrap the infant in anothe r clean, dry
cloth. Cover the head with a cap to re duce heat loss.
– Kee p the infant in a warm room (at least 25°C).
– Place the infant skin-to-skin against the mother’ s (drie d) body and cove r with a dry cloth
or blanket.
–Do not bathe the infant for 6 to 12 hours after bi rth.
The axillary tempe rature should be kept between 36 and 37°C, and the infant should have
pink, warm feet.
10.1.6 Feeding
– Exclusive breastfeeding is the best option (Appendix 3).
–Put the infant to the breast as soon as possible within an hour of birth.
– Encourage breastfeeding on demand day and night (at least 8 times/24 hours, i.e. every
3 hours).
–If the mother is HIV-infected, see Appendix 3, Section 3.7.
10.1.7 Preventive treatments
Routine prophylaxis for gonococcal ocular infection
For all infants:
Apply 1% tetracycline eye ointment: a 1-cm strip in each eye as soon as possible, preferably
within an hour of bi rth.
Note: if the mother has a symptomatic genital infection at the time of delivery, see Section10.4 .
Routine prophylaxis for haemorrhagic disease of the newborn
phytomenadione (vitamin K 1) IM in the anterolateral aspect of the thigh within the first few
hours of l ife:
Infant wei ghing more than 1500 g: 1 mg as a si ngle dose (0.1 ml if 2 mg/0.2 ml ampoul e)
Infant wei ghing less than 1500 g: 0.5 mg as a si ngle dose (0.05 ml if 2 mg/0.2 ml ampoul e)
Note: open ampoules of phytomenadione should be used immediately or discarded. Do not
store open ampoul es, even in the refri gerator.
Prevention of mother-to-child HIV transmission
All infants of HIV-infected mothers should receive antiretroviral treatment as soon as possible.
See the specific PMTCT protocol.Newborn care in the mate rnity hospi tal
20310

10.1.8 Vaccinations
The monovalent Hepatitis B and BCG vaccines are recommended as soon as possible after
birth for all newborns, including low birth weight and premature infants. The oral polio
vaccine is recommended at birth in endemic areas or areas at risk of poliovirus importation.
For the Hepatitis B and oral Polio vaccines, the dose administered at birth is an extra dose
(called and recorded as “Dose 0”). It does not count as one of the 3 doses required by the
Expanded Programme on Immunization during the postnatal period.
The purpose of Hepatitis B Dose 0 is to prevent mother-to-child transmission of the disease.
It should be administered as soon as possible, preferably within the first 12 hours of life.
While it may still be administered after that time, the later the vaccine is administered, the
less effective the protection1,2. In principle, this vaccine should be administered in the
delivery room.
Table 10.3 – Neonatal vaccination
*Start the infant on isoniazid preventive therapy, and administer the BCG vaccination when the isoniazid
therapy is completed.
Note : to perform an IM injection in newborns:
– Disinfect the skin beforehand (risk of abscess and other infections).
– Use the anterolateral aspect of the thigh (quadriceps muscle). Never inject into the
gluteal or deltoid muscle (arm).
– Use the appropriate needle: 26G if < 2500 g; 23G if > 2500 g.
– The maximum amount to inject is 1 ml if < 2500 g; 2 ml if > 2500 g.
10.1.9 Daily monitoring
Newborn (and maternal) mortality is the highest in the first 24 hours after birth. Women are
encouraged to stay for 24 hours in the maternity.
Routine monitoring and care includes:
– Temperature, heart and respiratory rate, twice daily.
– Cord disinfection once the first day (use the available antiseptic, Section 10.1.2 ). After
that, keep it clean, dry and exposed to the air (no dressing).
– Support to breastfeeding.
– Urination and stool production.
Record the observations on the newborn’s monitoring sheet.
For the discharge criteria: see Section 10.6.Vaccin Contra-indications Dose/route of administration
Hepatitis B
monovalent
Dose 0No contra-indication, but use only
the monovalent vaccine (Hepatitis B
only)One dose = 10 micrograms
IM injection, anterolateral aspect of
the thigh
BCG Newborn whose mother has active
TB as long as she is contagious
(Section 10.4.6)*One dose = 0.05 ml
Intradermal injection, deltoid
region (at the junction of the lower
2/3 and upper 1/3 of the lateral
aspect of the upper arm)
Polio oral
Dose 0No contra-indication One dose = 2 drops
Oral routeChapter 10
204Updated: April 2017

10.2 Neonatal resuscitation
10% of newborns need help breathing properly at birth; this help comes in the form of tactile
stimulation and/or airway clearing.
For half of them, these proce dures are not sufficient, and if the newborn is not breathing or
is gasping despi te stimulation/suction, ventilation is ne eded as of the first mi nute of life.
A small percentage of venti lated newborns wi ll require more advanced re suscitation.
The birth attendant in charge of the delivery is also responsible for the newborn. S/he
should start re suscitation i mmediately the n, if necessary, cal l for help.
Anticipate the potential need for resuscitation at every birth. The necessary
equipme nt should be ready at hand and ready for use .
Hypothermia compromises resuscitation. Resuscitation should be done in a heated room, if
possible under a warming l amp.
10.2.1 Basic resuscitationa
Steps 1 to 6 should be performed in the first minute of l ife.
1 – Check for meconium
If the amniotic fluid is meconium-stained but the infant is breathing spontaneously and is
tonic: suction is not indicated; simply wipe the face.
If the amniotic fluid is meconium-stained and the infant is not breathing well or is hypotonic:
quickly but gently suction the mouth, preferably with a suction bulb (Penguin).
2 – Stimulate the infant by drying
Tactile stimulation can trigger spontaneous breathing. It is done by drying the infant
vigorously, but not roughly. Effective respiratory effort should begin within 5 seconds. If not,stop the stimulation; the infant requires additional care.
3 – Clamp and cut the cord
4 – Position the infant’s head
Lay the infant on the back with the head in a neutral position (Figure 10.1); avoid flexion or
hyperextension of the neck, as this can obstruct the ai rway.
Correct Incorrect Incorrect
Figure 10.1
Head posi tion for cl earing the ai rway
aFor more information, refer to the Helping Babies Breathe training course.!
!
!
!
Newborn care in the mate rnity hospi tal
20510

5 – Clear the airway (only in the rare cases where there are copious secretions)
Suction the mouth gently – i.e., not too deeply (maximum depth 2 cm from the lips) – and
quickly (maximum duration 5 seconds) with a bulb syringe.
6 – Stimulate the infant
Rub the back and the soles of the feet (do not shake, slap or hang the infant by the feet). If
effective respiratory effort has not begun after 5 seconds: stop the stimulation; the infantrequires ventilation.
7 – Perform bag-mask ventilation (room air)
Fit the mask to the infant’s face covering nose and mouth. Press firmly to prevent air leaks.
Hold it with one hand, with the thumb on one side and the index and middle fingers on theother (Figures 10.2 and 10.3).
With the other hand, squeeze the bag at a rate of 30 to 50 compressions per minute for
60 seconds.Ventilation is effective if the chest rises and falls.Note: excessive ventilation pressure can cause pneumothorax.
If the chest fails to rise:
–Check the connection between the bag and the mask;–Correct the position of the mask on the face;–Correct the head position.
Correct Incorrect Incorrect Incorrect
Figure 10.2
Mask position
Figure 10.3
Manual ventilation
Check every minute for spontaneous respiratory effort (look for chest movement); do nottake the mask off the infant’s face to check for spontaneous breathing.
Continue manual ventilation until there is spontaneous respiratory effort.!
!
!
!
!
!
!
Chapter 10
206

If oxyge n is available: connect the ambu bag to an oxygen reservoir after 1 to 2 minute s of
ventilation, setting it at a 2 litres/minute flow rate. Ventilation is a priority and should not
be interrupted to connect the oxygen (have an assistant connect the oxygen).
Stop resuscitation if the infant has no heart rate after 10 minutes or if the heart rate is
< 60/minute of effective manual ventilation.If the infant has a heart rate > 60/minute, but does not breathe spontaneously, manualventilation can be continued. However, resuscitation should be stopped if the infant doesnot breathe spontaneously within 30 minutes.
Record all procedures on the monitoring sheet.
10.2.2 After resuscitation
Check the infant’s immediate needs: blood glucose, head position, oxygen saturation,
temperature and assessment for signs of sepsis.
Perform a retroactive Apgar score assessment (Section 10.1.3), and record the results on the
monitoring sheet.If the Apgar score was ≤ 4 at 1 minute or ≤ 6 at 5 minutes, or if the infant was ventilatedwith a mask for 2 minutes or more:– Hospitalise in a neonatal care unit (keep the mother and infant together if possible).–If transfer is not possible, keep the infant under observation for at least 24 hours. Monitor
every 2 hours: look for danger signs ( Section 10.3.1 ) and monitor vital signs. Ensure
routine care (Section 10.1). Be gin breastfeeding as soon as possi ble.
If the infant is floppy, has no sucking reflex or exhibits other neurological problems (e.g.
seizures), check blood glucose. If blood glucose cannot be checked, start presumptive
treatment for hypogl ycaemia (Section 10.3.5).
If oxygen saturation is low or there are signs of respiratory di stress, see Section 10.3.2.
In the event of sei zures:
– Che ck blood gl ucose and/or treat for hypogl ycaemia.
–If the infant continue s to have seizures after receiving glucose, administe r a loading dose
of
phenobarbital (20 mg/kg) by slow IV infusion (dilute the require d dose of phenobarbital
in 20 ml of 0.9% sodium chloride and administer over 30 minutes). Never administer
phenobarbital as a rapid, undiluted direct IV injection. If intravenous access cannot be
obtained, administe r the same dose of phe nobarbital (undi luted) by IM i njection.
– Precaution should be taken when administering phenobarbital; there is a risk of
respiratory depression: monitor the infant cl osely; have venti lation equipment at hand.
– If seizures persist after 30 minutes, give a second dose of phenobarbital (10 mg/kg) by
slow IV infusion over 30 minutes as above. If IV access cannot be obtained, administer the
second dose (10 mg/kg) of phenobarbital undiluted by IM injection 60 minutes minimum
after the first IM dose.
–In any cases, monitor the infant cl osely for at least 6 hours.
–For recurrent sei zures, administer phenobarbital PO: 5 mg/kg/day for 5 days.Newborn care in the mate rnity hospi tal
20710

10.3 Care of the sick newborn
10.3.1 Danger signs
Routinely check all newborns for dange r signs at birth and during their stay in the maternity
hospital. Danger signs i ndicate severe infection and re quire immediate care.
*Subtle movements: sucking or chewing, blinking or disorganised eye movements, disordered arm or leg
movements (pedal ling).
10.3.2 Management of life-threatening emergencies
Cyanosis and/or respiratory distress
– Position the head to open the ai rway.
– Administer oxygen with an appropriate nasal cannula, at a maximum flow rate of
2 litres/minute, monitoring with a pulse oxymeter. The oxygen saturation in full-term or
premature infants should be 90 to 95%.
Use an appropriate paediatric flow splitter so that the oxygen flow can be adjusted
correctly when there are several infants on the same oxygen concentrator.
– Place a gastric tube for feeding (Appendix 5).Danger signs
Temperature > 38°C: hyperthe rmia
< 35.5°C: hypothermia
Neurological signs Seizure s (including subtle* or “abnormal” movements)
Bulging fontanelle
Inability to suckle effectivelyLethargy or comaHypotony
Respiration Apnoea (respiratory pause > 20 seconds or combined with
bradycardia)Bradypnoea (respiratory rate < 30/mi nute)
Tachypnoea (re spiratory rate > 60/mi nute)
Grunting respi rations
Chest indrawing
Abdomen Severe abdominal distension
Skin colour Generalised cyanosis (blue col ouring)
Extreme pallor
Skin Umbilicus red or oozing blood or pusNumerous or large pustules
Joints Swollen, painful joint (irritability when moved) with reduced joint
movement
Blood glucose Recurrent hypogl ycaemia (> 2 epi sodes)Chapter 10
208

Apnoea or bradypnoea
– Perform bag-mask ventilation (add oxygen if the ventilation lasts more than 1 to
2 minutes).
Impaired consciousness and/or seizures
– Che ck the blood glucose or, if that is not possi ble, treat hypogl ycaemia (Section 10.3.5).
– Administer phenobarbital in case of seizures (Section 10.2.2).
– Place a gastric tube for feeding (Appendix 5).
10.3.3 Management of symptomatic neonatal infections
A neonatal infection is likely and an antibiotic therapy and transfer to neonate unit are
required:
–The first-line treatment is the combi nation ampicillin IV + gentamicin IM.
The ampicillin is preferably used IV; the IM route is an option if the context does not
permit proper IV administration. To avoid multiple IM injections, however, it may be
better to use procaine benzylpenicillin IMb+ gentamicin IM or, as a last resort (if procaine
benzylpenicillin is not available) ceftriaxonecIM + gentamicin IM.
–If meningitis is suspected, do not use procaine benzylpenicillin.
–If the infection is cutaneous in origin, replace the ampicillin with cloxacillin IVd.
bProcaine benzylpenicillin may be replaced by fortified penicillin procaine (PPF), same doses. These two
penicillins SHOULD NEVER BE USED INTRAVENOUSLY.cCeftriaxone is contra-indicated in newborns with jaundice.dDue to the risk of local necrosis, cloxacillin should be administered by IV infusion in 5% glucose or 0.9%
sodium chl oride over 30 to 60 minutes (or if i mpossible, by slow IV i njection over at least 5 mi nutes).In presence of one of these danger
signs
OR
In presence of two of these danger
signsorIf one these danger signs persist formore than one hour– Hyperthermia– Seizures– Bulging fontanelle–Apnoea – Severe abdominal distension– Generalised cyanosis– Umbilicus red or oozing blood or pus– Numerous or large pustules– Swollen, painful joint with reduced joint
movement
–Recurrent hypogl ycaemia (> 2 epi sodes)
– Hypothermia– Inability to suckl e effectively
–Lethargy or coma
– Hypotony– Bradypnoea– Tachypnoea– Grunting respi rations
– Che st indrawing
– Extreme pallorNewborn care in the mate rnity hospi tal
20910

Symptomatic neonatal infections are treated for a total of 10 to 14 days. This may be
shorted to 7 days if there is complete recovery in the first 24 hours. It should never be less
than 7 days and never given orally. Gentamicin should usua lly be stopped after 5 days of
treatment.
Premature and low birth weight infants are at greater risk of serious i nfection.
Table 10.5 – Antibiotic dosages for newborns less than 7 days ol d
In all cases, while awaiting the transfer in neonatal intensive care unit:
–Start anti biotic the rapy.
–Ensure routi ne newborn care (Section 10.1).
– Keep the infant warm in a 25°C room, wrapped in a survival blanket or under a warming
lamp if possi ble, and cover the head with a cap.
– Closely monitor temperature , respiratory rate and oxygen saturati on.
10.3.4 Management of asymptomatic newborns at risk of neonatal
infection
In asymptomatic newborns (no danger signs), neonatal infection should nevertheless be
suspected if any of the risk factors below are present.
Major risk factors (RF)
– Peripartum maternal fever (To ≥ 38°C before del ivery or during l abour)
– Chorioamnionitis (foul -smelling, cloudy amni otic fluid)
– Prolonged rupture of membranes l asting > 18 hours before del ivery
Minor risk factors
– Birth weight < 2000 g
– Resuscitation at birth with manual ventilation– Meconium-stained amniotic fluid: this is a risk factor for neonatal infection, but not in
itself an indication for antibiotic therapy. Meconium-stained amniotic fluid is also a risk
factor for pneumothorax and aspi ration pneumoni a.
eProcaine benzylpenicillin may be replaced by fortified penicillin procaine (PPF), same doses. These two
penicillins SHOULD NEVER BE USED INTRAVENOUSLY.AntibacterialBirth weight
≤ 2000 g > 2000 g
ampicillin
IV/IM injection100 mg/kg/day in 2 di vide d doses
If meningitis:200 mg/kg/day in 3 divided doses150 mg/kg/day in 3 di vide d doses
If meningitis:300 mg/kg/day in 3 divided doses
gentamicinIM injection 3 mg/kg once dai ly 5 mg/kg once dai ly
procainebenzylpenicillin
e
IM injection50 000 IU/kg once dai ly
If meningitis: do not admi nister.
ceftriaxoneIV/IM injection 50 mg/kg once dai ly
If meningitis:100 mg/kg once daily
cloxacillinIV infusion 50 mg/kg/day in 2 di vided dose s 75 mg/kg/day in 3 di vided dose sChapter 10
210

Criteria for suspecting asymptomatic neonatal infection
Management of suspected asymptomatic neonatal infection (one of the criteria above)
– Administer antibiotics for 48 hours3: ampicillin IV + gentamicin IM or fortified penicillin
procaine IM + ge ntamicin IM. See Table 10.5 for dosage .
– Monitor for dange r signs (Section 10.3.1). If the infant presents at least one danger sign,
see Section 10.3.3.
–If the infant has not presented any of the danger signs during the first 48 hours, stop the
antibiotics and keep under obse rvation for an addi tional 48 hours.
–If the infant has not presented any of the danger signs during the observation period or at
the discharge clinical examination (preferably done by a doctor): send home . In this case,
tell the parents which signs re quire immediate consultation.
Management for all other asymptomatic newborns (none of the cri teria above)
– Kee p under obse rvation in the maternity hospi tal for 24 hours.
– Monitor for dange r signs (Section 10.3.1). If the infant presents at least one dange r sign,
see Section 10.3.3.
–If the infant did not present any danger signs during observation: send home. In that case,
tell the parents which signs re quire immediate consultation.
10.3.5 Management of hypoglycaemia
Criteria defining newborns at risk for hypoglycaemia
–Presence of at least one of the fol lowing signs:
• Hypothermia (axi llary temperature < 35.5°C)
• Irritability or trembl ing
•Bradypnoea or apnoea or cyanosi s
• Difficulty breastfeeding (difficulty attaching to the breast, difficulty sucking, inadequate
milk producti on)
•Hypotony or poor response to sti mulation (i mpaired consci ousness)
• Seizures
fAntibiotics during labour when there is a prolonged rupture of membranes ( Chapter 4, Section 4.9.3 ) reduces
risk of septicaemia in the newborn. Coverage is considered effective if at least 2 doses have been administered
4 hours apart during labour.–1 major RF if the mother did not receive antibiotics during labour (or received less than
2 dosesf)
or
–1 major RF and birth weight < 2000 g, whether the mother received antibiotics during
labour or not
or–≥ 2 major RFs, whether the mother received antibiotics during labour or notor–1 major and ≥ 2 minor RFs, whether the mother received antibiotics during labour or
not
or–≥ 3 minor RFs, whether the mother received antibiotics during labour or notNewborn care in the mate rnity hospi tal
21110

– Birth weight < 2500 g or > 4000 g
– Maternal diabetes– Mother treated with labetalol
Always check blood glucose
gif at least one of the above cri teria is prese nt.
Management
If the blood glucose is normal (> 2.5 mmol/l or > 45 mg/dl):
– Breastfeeding every 3 hours (add 10% glucose PO if breastfeeding is insufficient).– Keep the infant warm.–Check the blood glucose before each meal until there are 3 consecutive normal results.
If the hypoglycaemia is moderate (2 to 2.5 mmol/l or 35 to 45 mg/dl) and it is the first
episode of hypoglycaemia:– Put to the breast and give 5 ml/kg of 10% glucose over 5-10 minutes PO or by gastric
tube, or
– Administer 2 ml/kg of 10% glucose by IV infusion as below, if an IV line is already in place
and if the newborn is symptomatic.
– Check the blood glucose after 30 minutes; administer IV glucose if blood glucose is
< 2.5 mmol/l (< 45 mg/dl).
–Check the blood glucose before each meal until there are 3 consecutive normal results.
If the hypoglycaemia is severe (< 2 mmol/l or < 35 mg/dl) or recurrent:
– Place an IV line and administer 2 ml/kg of 10% glucose.–If not feasible, administer 10 ml/kg of 10% glucose by gastric tube.– Then start a continuous infusion of glucose 10%: 80 ml/kg/day for at least 24 hours, if
conditions permit.
– Check the blood glucose after 30 minutes and then before each meal until there are
3 consecutive normal resul ts.
The use of 50% glucose (1 ml/kg) sublingually is recommende d only if it is impossible to do
an infusion or place a gastric tube.
10.3.6 Management of jaundice
Severe jaundice can cause acute encephalopathy, potentially leading to neurological
sequelae and death.
Diagnosis
Jaundice is yel low colouring of the skin and mucous membranes due to hyperbi lirubinaemia.
It appears first on the face, and then moves to the chest and then the extremi ties.
The examination should be done in day light. It is done by pressing the infant’s skin and
looking to see if it is yel low immediately after the pressure is removed.
Jaundice can be physiologic, with a yellowish skin colour, without the criteria for pathological
jaundice bel ow.
Physiologic jaundice is a diagnosis of exclusion in an infant in excellent general condition
who is feeding wel l and whose neurol ogical exami nation is normal .
gBlood glucose is measured on a sample of capillary blood taken from the lateral aspect of the heel using a
lancet or 24G needle. This technique is used for other tests like HemoCue haemoglobin measurement.Chapter 10
212

Pathological jaundice starts the first day of life (the second day of life if < 35 weeks), and
lasts more than 14 days in ful l-term infants or more than 21 days in premature i nfants.
It is an intense colour that affects the palms of the hands and soles of the feet, and may be
associate d with a neonatal i nfection.
In cases of jaundi ce, consider se pticaemia or congeni tal malaria.
Management
Infants presenting criteria of severity (early onset jaundice, extensive jaundice, low birth
weight, or spe cific risk) should be re ferred.
Table 10.6 – Cri teria for transferring newborns with jaundi ce to neonatal uni t
If there are no cri teria of seve rity or whi le awaiting the transfer:
– Maintain good hydration (breastfeeding), if necessary use infant formula and a gastric
tube.
– Begin treatment for i nfection, if present.
–Sun exposure is not an effective treatment for severe jaundice. However, if there are no
other options, expose the bare newborn to the sun for 10 minutes 4 times a day, in the
morning and late afternoon, when the sun is not too strong.
Cover the i nfant’ s eyes.Time of onset Criteria for transfer
Day 0 – All newborns, regardless of birth wei ght
Day 1 – Newborns < 1500 g
– Newborns > 1500 g with extensive jaundice: head, chest, abdomen,
uppe r arms and thi ghs
Day 2 or later – Newborns < 1500 g with very extensive jaundice (head, chest, abdomen,
uppe r arm and fore arm, thigh and l owe r leg)
– Newborns > 1500 g wi th:
• very extensive jaundice (head, chest, abdomen, upper arm and
forearm, thigh and l owe r leg)
AND
•at least one of the following risk factors: ABO or Rh incompatibility,
G6PD deficiency, inadequate breastfeeding, infection, hypothermia,
asphyxia, cephalohaematoma or maternal di abetes
– Newborns > 1500 g with no risk factors but extreme jaundice also
affecting the palms of the hands and sol es of the fe etNewborn care in the mate rnity hospi tal
21310

10.4 Specific care when the mother has a transmissible
infection
10.4.1 Syphilis
Look for signs of syphi lis in all infants of mothers with a posi tive syphi lis test:
–Mucocutaneous rash, grey patches, papules and bullae followe d by desquamation of the
skin on the palms and sol es of the fe et;
– Sepsis, jaundice, anaemia, enlarged lymph nodes and abdominal distension with
hepatosplenomegaly.
If the infant has no signs of syphilis and the mother receive d appropriate treatment during
the pregnancy (at least one dose of penicillinhadministered at least one month before
delivery), give the infant: benzathine benzylpenicillin IM, 50 000 IU/kg as a si ngle dose.
If the infant has signs of syphilis or the mother did not receive appropriate treatme nt (see
above):
– Administer to the infant:
benzylpenicillin IV for 10 days: 100 000 IU/kg/day in 2 divided doses given 12 hours apart
from Day 0 to Day 7, and then 150 000 IU/kg/day in 3 divided doses given 8 hours apart
from Day 8 to Day 10
–In addition to “standard” precautions, use “contact” precautionsiduring care for 24 hours
after starting the treatme nt.
10.4.2 Genital gonococcal and/or chlamydial infection
Newborns of mothers with purulent cervical discharge at the time of delivery may be
asymptomatic or present purulent conjunctivitis, usually within the first 7 days for
gonorrhoe a and after 7 days for chl amydia. Chl amydial pneumonia is possi ble.
Administe r ceftriaxone IM: 50 mg/kg as a si ngle dose (maximum 125 mg) to:
– All infants with purulent conjunctivitis, whether the mother is symptomatic or not;
– All infants born to mothers who were symptomatic at the time of delivery, even if the infants
are asymptomatic.
In case of symptomatic conjunctivitis (purulent discharge): clean each eye with 0.9% sodium
chloride at least 4 times a day.
If the conjuncti vitis persists 48 hours after the ceftriaxone i njection, administer :
erythromycin PO: 25 to 50 mg/kg/day in 4 di vided doses for 14 days
or azithromycin PO: 20 mg/kg once dai ly for 3 days
If the symptoms appear after 7 days of life, administer ceftriaxone IM + erythromycin or
azithromycin PO, as above.
hErythromycin is not an appropriate treatment.iContact precautions include: isolation of the infant, use of gloves and protective gown at each contact with
the infant.Chapter 10
214Updated: October 2016

10.4.3 Genital herpes4
Infants of mothers who have active genital herpes lesions at the time of delivery may
present with neonatal herpes.
The infant is usually asymptomatic at birth. The symptoms appear sometime within the first
4 weeks of l ife (usual ly between 3 and 10 days of l ife).
Symptoms of neonatal herpes may i nclude:
– Local, external involvement: skin, mouth (vesi cles) and/or e yes (conjuncti vitis);
– Cerebral involvement: encephalitis (with seizure s in 60% of cases), accompanied in 60% of
case s by local external involvement;
– Disseminated infection: primarily brain, lungs and liver. The infant may present danger
signs suggesting septicaemia (fever, lethargy, respiratory distress or seizure). Local external
involvement is associ ated in 60% of cases.
Manageme nt depends on the i nfant’ s risk at bi rth:
High risk of herpes infection
–Infant with symptoms of ne onatal herpes, or
– Active primary or unknown maternal ge nital herpes at the time of del ivery, or
– Active recurrent maternal genital herpe s at the time of delivery, with at least one of the
following risk factors: rupture of membrane s ≥ 6 hours before delivery (vaginal delive ry or
caesare an section) or birth weight < 2000 g or premature ≤ 37 wee ks or skin laceration or
maternal HIV i nfection.
In these cases, 3% aciclovir eye ointment: a single application in each eye at birth (in this
case, wait 12 hours before applying tetracycline eye ointment, Section 10.1.7) and refer to
neonatal care unit for aci clovir IV the rapy, with isolation of mother and i nfant.
Low risk of herpes infectionRecurrent acti ve genital herpes with none of the risk factors l isted above.
In these cases, observe for 5 days, with i solation of the mother and i nfant.
Apply 3% aci clovir eye oi ntment, as above.
If the infant becomes symptomati c, refer to ne onatal care unit for aci clovir IV therapy.
Discharge at 5 days of life if the infant has not developed symptoms; ask pare nts to seek
urgent attention if symptoms appear.
10.4.4 Hepatitis B infection
The infant is asymptomati c.
Administer Hepatitis B vaccine to the infant at birth, regardless of the mother’s serological
status (Section 10.1.8).
10.4.5 HIV infection
The infant is asymptomati c.
Administer antiretroviral prophylaxis immediately after birth: refer to the PMTCT-specific
guides.For breastfeeding: see Appendix 3, Section 3.7.Newborn care in the mate rnity hospi tal
21510

10.4.6 Active pulmonary tuberculosis
Congenital tubercul osis is rare , and the infant is usual ly asymptomatic at bi rth.
Afte r birth, the mothe r can transmit tuberculosis to the infant as long as she is contagious,
i.e. sputum smear posi tive or culture posi tive.
In that case :
–Do not admi niste r BCG.
– Administer preventive therapy to the infant, isoniazid PO: 10 mg/kg once daily for
6 months.
– Administer the BCG vacci ne after compl etion of isoniazid the rapy.
– Do not separate the mother from the infant (breastfeeding, etc.), but observe the
rules for transmission prevention. For more information, refer to the MSF handbook,
Tuberculosis.Chapter 10
216

10.5 Care of the low birth weight newborn (1500-2500 g)
Low birth weight indicates prematurit y (less than 37 weeks) or intrauterin e foeta l growth
retardation or a combi nation of the two.
Low birth weight newborns, whethe r premature or not, are at significant short-te rm risk of
hypothermia, hypoglycaemia, apnoea, respiratory distress, jaundice, infection, anaemia,
dehydration and feeding problems, and at significant long-term risk of poor psychomotor
development.
Newborns who are sick or who weigh less than 1500 g should be referre d to a neonatal care
unit whenever possi ble.
Newborns who weigh 1500 to 2500 g, regardless of the term, are managed in the maternity
hospital if they are not sick, according to the recommendations below.
10.5.1 Kangaroo care
(Figures 10.4)
The Kangaroo mother carejis a method of caring for infants that involves putting them on
the mother's chest ski n-to-skin, prefe rably 24 hours a day.
This method can be used for all non-sick infant whose birth weight is less than 2500 g
(prematurity and/or i ntrauterine foe tal growth retardati on).
The bare infant is place d vertically against the mother’ s chest; the mouth should always be
able to reach the ni pple. Use a pagne to hold the i nfant.
If needed, use a blanket to keep the mother and infant warm.
When the mother is sl eeping, her bust should be rai sed and the infant should be moni tored.
Figures 10.4
Kangaroo care
jFor more information: World Health Organization. Kangaroo mother care: a practical guide. 2003.
http://www.who.int/maternal_child_adolescent/documents/9241590351/en/!
!
!
!
!
!
Newborn care in the mate rnity hospi tal
21710

The objectives of the Kangaroo care are :
–To keep the infant warm and to prevent or treat hypothermia.
–To help get breastfeeding started and keep it going.–To foster the mother-infant bond and reduce the infant’s stress.–To reduce episodes of apnoea and bradycardia in premature infants.
Note: the skin-to-skin contact can also be done by the father, another family member or a
wet-nurse during periods when the mother is not available.
10.5.2 Thermoregulation
–Cover the i nfant’ s head to re duce heat loss.
– Make sure that the room temperature is at least 25°C.
–Use the Kangaroo care (Section 10.5.1).
10.5.3 Feeding
– Exclusive breastfe eding is the best choice (Appendix 3).
– If sucking is ineffective but the swallowing reflex is present: express the milk manually
or using a breast pump and feed the infant using a cup/spoon (Appendix 3, Sections 3.2and 3.3).
–If sucking is ineffective and the swallowing reflex is poor or absent: express the milk and
feed the infant using a gastric tube (Appendix 3, Sections 3.2 and 3.4).
–For the daily amounts required for feeding, see Appendix 4.–If the mother does not have enough milk:
•In the first 72 hours of life, make up the required amounts with 10% glucose PO.•After 72 hours of life, make up the amount with infant formula (or if not available, use
diluted F 100 milk
k).
At the same time, continue to stimulate the mother’s milk production (breast pump andthe “supplementary nursing" technique, Appendix 3, Section 3.5).
–For newborns less than 1500 g, glucose is routinely given in addition to the mother’s milk
(Appendix 4).
In case of regurgitation:– Administer each meal very slowly.– Hold the infant tilted slightly head-up.
In case of vomiting, abdominal distension, blood in the stool or greenish, foul-smelling stool,
stop feeding and request a medical opinion.
In all cases, try putting the infant to the breast periodically to test if breasfeeding is effective
or not.
10.5.4 Monitoring
Same moni toring as for a newborn > 2500 g, pl us:
– Daily weighing;
– Temperature every 4 hours;– Blood glucose test before every meal or every 3 hours until there are 3 consecutive normal
results. In case of hypoglycaemia, see Section 10.3.5.
kDiluted F-100 milk: 1 sachet (456 g) of F-100 milk in 2800 ml of water.Chapter 10
218

10.6 Criteria for discharge from the maternity hospital
AND
AND– No danger signs (Section 10.3.1).
– Appropriate management of neonatal infection (Sections 10.3.3and 10.4) and risk
factors for neonatal infection (Section 10.3.4).
– Healthy infant: good breastfeeding on demand, normal respiration and temperature,
etc.
– Weight > 1500 g.
– Preventive treatments (Section 10.1.7) and BCG, Hepatitis B (0) and Polio (0) vaccines
administere d (Section 10.1.8).
– Clinical record filled out (including discharge weight).
– Postnatal visit appointment (Chapter 11, Section 11.3) given.
Information for the mother
1) Breastfeeding: Appendix 3.2) Infant care:
•Wash the infant with soap and water once a day, and immediately dry with a towel or
cloth to avoid hypothermia.
• Cord care: clean with soap and water each time it is soiled, rinse well and dry then let it
uncovered. Do not apply an antiseptic or other product or dressing on the cord. The cord
falls between the 5
thand 15thday after birth.
• Kangaroo care if weight < 2500 g (Section 10.5.1).
•Lay infant on the back.
•Use a mosquito net day and night when the infant sl eeps.
• Keep the infant away from sick (contagious) chi ldren and adul ts.
•Wash hands before and after caring for the i nfant.
• Dispose of stool in the l atrine.
3) Danger signs requiring a consultation:
• Inability to breastfeed properly
• Abnormal movements•Reduced activity• Trouble breathing• Abnormal colouring•Redness or purulent discharge from the umbilicus•Fever or hypothermiaNewborn care in the mate rnity hospi tal
21910

References
1Weekly epidemiological record/Relevé épidémiologique hebdomadaire : Hepatitis B
vaccines/Vaccins anti-hépatite B, 2 octobe r 2009, 84thyear/2 octobre 2009, 84eannée,
No. 40, 2009, 84, 405–420.
http://www.who.int/wer/2009/wer8440.pdf
2Vaccines. Sixth edition by Stanley Plotkin, Walter Orenstein and Paul Offit (2013).
3Pocket book of hospital care in children, second edition, World Health Organization, 2013.
http://www.who.int/maternal_child_adolescent/documents/child_hospital_care/en/
4Neonata l herpes simplex virus infection : Management and prevention , Gail J Demmler-
Harrison, UpToDate, Literature review current through: Oct 2013, last update: Mar 7, 2013.Chapter 10
220

Chapter 11:
Postpartum/postnatal period
11.1 Normal postpartum events ………………………………………………………………………223
11.1.1 Uterine involution …………………………………………………………………………..223
11.1.2 Lochia …………………………………………………………………………………………..223
11.1.3 Lactation ………………………………………………………………………………………223
11.1.4 Return of menstrual periods …………………………………………………………….223
11.2 Postpartum care for the mother ……………………………………………………………….224
11.2.1 In the maternity hospital …………………………………………………………………224
11.2.2 Upon discharge ……………………………………………………………………………..225
11.3 Postnatal consultations ……………………………………………………………………………226
11.3.1 Timing of postnatal consultations …………………………………………………….226
11.3.2 For the mother ………………………………………………………………………………226
11.3.3 For the infant …………………………………………………………………………………227
11.3.4 Postnatal care card ………………………………………………………………………..227
11.4 Postpartum complications ……………………………………………………………………….228
11.4.1 Excessive uterine bleeding ……………………………………………………………….228
11.4.2 Infectious complications ………………………………………………………………….228
11.4.3 Breast-related complications …………………………………………………………..229
11.4.4 Urine leakage ………………………………………………………………………………..229
11.4.5 Psychological disorders …………………………………………………………………..230
11.5 Contraception …………………………………………………………………………………………231
11.5.1 Contraceptive methods …………………………………………………………………..231
11.5.2 For women who are breastfeeding …………………………………………………..232
11.5.3 For women who are not breastfeeding ……………………………………………..232
11.5.4 Special situations ……………………………………………………………………………233
11

11.1 Normal postpartum events
The postpartum period extends from delive ry to six wee ks after delivery. This is the time it
takes for the uterus to return to its initial size and for pregnancy-related biological and
hormonal changes to di sappear.
11.1.1 Uterine involution
–After the de livery of placenta, the uterus contracts and be come s hard. It is pal pable bel ow
the umbi licus.
–Around the fifth or sixth day, it is halfway between the navel and the symphysis pubi s.
–Around the tenth day, it is at the symphysis pubi s.
–After six week s, it returns to its normal si ze.
– The internal os closes between the eighth and twelfth day.
11.1.2 Lochia
Vaginal discharge, which is bloody during the first three days and then blood-tinged. It is
usually odourl ess and stops after 15 to 21 days.
11.1.3 Lactation
The first two days: secre tion of yel lowish col ostrum.
Around the third day, breast tenderness, sometimes accompanie d by a short-live d feve r of
38-38.5°C. The composition of the milk changes: mature milk, which is whiter and more
abundant.
11.1.4 Return of menstrual periods
The first menstrual period usually occurs betwee n the sixth and eighth week in wome n who
are not breastfe eding.Postpartum/postnatal period
22311

11.2 Postpartum care for the mother
More than 60% of maternal deaths occur in the postpartum period and 45% of postpartum
deaths occur within the first 24 hours. Women should therefore remain in the health care
facility for at least 24 hours1after delivery.
11.2.1 In the maternity hospital
Following the immediate post-partum (Chapter 5, Section 5.2.2), monitor during the first
day (and dai ly if the patient stays for more than 24 hours):
– Vital signs (heart rate, blood pressure, te mperature, respiratory rate) 2 ti mes/day.
– Uterine i nvolution.
– Vaginal bl eeding.
– Perineal te ar/episiotomy scar.
– Urination and i ntestinal transi t.
– Signs of anaemia (if pre sent, measure haemogl obin).
Record all information in the pati ent’s chart.
In case of cae sare an section, see Chapter 6, Se ction 6.4.
Inform and advise the mother:
– Personal hygie ne (clean the perine um daily with soap and water, change sanitary napkins
every 4 to 6 hours).
– Mobilisation and ambul ation to pre vent thrombosi s.
–Infant care (Chapte r 10, Section 10.6).
– Breastfeeding (Appendix 3).– Maternal danger signs re quiring immediate consul tation:
• significant vaginal bleeding (e.g., sanitary napkin needs to be changed every 20 to
30 minute s during 1 to 2 hours and/or e xpulsion of clots in various occasi ons),
• headache with visual disturbance or nausea and vomi ting; seizures,
• difficult or rapid breathi ng,
• fever,
• significant abdomi nal pain,
• foul-smelling vagi nal discharge.
– Contraception ( Section 11.5).
Special situations : intrauterine foetal death or neonatal death or chi ld abandonment
In the absence of contra-indication (cardiac valvulopathy, hypertension, preeclampsia,
history of postpartum psychosi s), lactation may be suppressed by usi ng:
cabergoline PO: 1 mg as a single dose on the first day postpartum to inhibit lactation or
0.25 mg every 12 hours for 2 days to suppress establ ished lactation.
Note: the use of cabergol ine is limited to the above parti cular situations.Chapter 11
224

If cabergol ine is not avai lable or contra-i ndicated:
–Do not use any other dopamine agonists such as bromocriptine.
–Do not compress the breasts by a bandage (uncomfortable and ineffective).– Wearing a bra at all times (day and night) and paracetamol can reduce the discomfort of
lactation. In the absence of stimulation, milk production stops within one to two weeks.
In addition, psychological support should be offered to all women at the maternity hospital
and in post-partum period. See Chapter 4, Section 4.11.2.
11.2.2 Upon discharge
– Schedule an appointment for the postnatal vi sit (Section 11.3).
– Verify that i nformation and advice were gi ven.
–If there is no clinical anaemia, continue iron + folic acid supplementation for 3 months1
(Chapte r 1, Section 1.2.5). In case of anae mia, see Chapte r 4, Section 4.1.Postpartum/postnatal period
22511

11.3 Postnatal consultations
11.3.1 Timing of postnatal consultations
Two postnatal consultations, for the mother and infant, should be offered within the first six
weeks after del ivery:
– The first within 8 days of delivery, especially for women who delivered at home. For
patients who delivere d in a health care facility and staye d there for more than 24 hours,
the discharge visit for the mother and infant is consi dere d the first postnatal consul tation.
AND
–The second vi sit within four to six weeks of del ivery for al l patients.
If the infant weighs less than 2000 g, a weekly consultation is recommended for the first
month, and then at 6 wee ks.
The postnatal consul tations are usual ly done in the maternity se rvices.
11.3.2 For the mother
– Asse ss vital signs: heart rate, blood pre ssure, temperature , respiratory rate.
– Asse ss uterine involution.
– Asse ss the heal ing of the i ncision in cases of cae sare an section.
– Examine the vulva and perineum: look for tears, assess the healing of episiotomy or
sutured wound, and appearance of vaginal discharge.
– Inquire about urination and intestinal transit. In case of urine leakage, look for potential
fistula (Chapter 7, Section 7.2.5).
–Check for breast lesions.
– Look for anaemia. If there is no clinical anaemia, continue iron + folic acid supplementation
for 3 months (Chapter 1, Se ction 1.2.5). In case of anae mia, see Chapter 4, Se ction 4.1.
–Perform a dipstick urinalysis if there are any symptoms of urinary tract infection and/or
fever and/or hyperte nsion.
– Offe r HIV counse lling and te sting if not done during pregnancy or del ivery.
– Note the mother-infant i nteraction, and the mother’s psychol ogical state.
– Provide information on contraception (time until fertility returns, available contraceptive
methods, efficacy, benefits, constraints, and adverse effects of each method) and
prescribe contraceptive if desired (Section 11.5).
– Administer vi tamin A ( retinol PO: 200 000 IU as a si ngle dose) if not done at del ivery.
– Complete tetanus immunisation if necessary.– Give information and advice (danger signs, hygiene, breastfeeding, use of insecticide-
treated mosquito nets for mother and infant).Chapter 11
226

11.3.3 For the infant
– Clinical e xamination:
• height, weight. A term infant should have regained birth weight by Day 10; infants less
than 2500 g normal ly regain the ir birth weight by Day 14 (unless they have been si ck);
• condition of umbi lical cord;
• presence/absence of danger signs (Chapter 10, Se ction 10.3.1);
• if there are signs of anaemia (pal lor of conjuncti vae, the palms of the hands and sol es of
the feet), measure haemogl obin.
Normally, the haemoglobin level of infants younger than 2 months and weighing less
than 2500 g at birth should not be < 7 g/dl. Refer to neonatal unit if the haemoglobin is
< 7 g/dl in a non-sick infant and < 10 g/dl in a sick i nfant.
– Apply tetracycline eye ointment (up to 8 days after birth) if not done at birth (Chapter 10,
Section 10.1.7).
– Administe r vitamin K1if not done at birth (Chapte r 10, Section 10.1.7). Catch-up can be
done up to age 3 months.
– Feeding: assess breastfe eding (Appendix 3).
– Vaccination:
Normally, vaccinations (Hepatitis B Dose 0, BCG, Polio Dose 0) are given at birth. They are
then continue d at 6, 10 and 14 weeks (Doses 1, 2 and 3 Polio and the pentavale nt vaccine
containing Hepatitis B). Follow the recommendations of the Expanded Programme on
Immunization.
If the infant did not receive vaccines at bi rth:
• Hepatitis B: Dose 0 may still be administered, but the later it is given, the less effective
it is in pre venting mother-to-chi ld transmi ssion.
• Polio and BCG: admi nister Dose 0 of the Pol io vaccine and the BCG vacci ne.
11.3.4 Postnatal care card
Register al l relevant information on an i ndividual post partum fol low-up card (Appendix 6).Postpartum/postnatal period
22711

11.4 Postpartum complications
11.4.1 Excessive uterine bleeding
Usually the amount of lochia is similar to a normal menstrual period. If the discharge is
heavier, consider the possi bility of retained products and/or endometri tis.
If suspicion of re taine d placenta:
– Digital curettage or manual vacuum aspiration or extremely cautious instrumental
curettage, with anti biotic coverage (Chapte r 9).
– Antibiotic therapy for 5 days:
amoxicillin/clavulanic acid PO (dose expressed in amoxi cillin): 3 g/day in 3 di vided dose s
or
amoxicillin PO: 3 g/day in 3 di vide d doses + metronidazole PO: 1.5 g/day in 3 di vided doses
11.4.2 Infectious complications
Look for an infectious complication in patients with feve r highe r than 38°C for more than
48 hours.
Postpartum endometritis and salpingitis
– Fever, usually high.
– Abdominal and/or pelvic pain, foul-smelling or purulent lochia.
– Physical exam: uterus enlarged, soft, painful when mobilized; open cervix; swelling in the
posterior fornix.
– Admit to inpatient department and start antibiotic therapy:
amoxicillin/clavulanic acid IV (dose expressed in amoxi cillin): 3 g/day in 3 di vided dose s
+ gentamicin IM: 3 to 5 mg/kg once dai ly
or
ampicillin IV: 6 g/day in 3 di vided dose s
+ metronidazole IV: 1.5 g/day in 3 di vide d doses
+ gentamicin IM: 3 to 5 mg/kg once dai ly
Continue this treatment for 48 hours after resolution of fever. Do not switch to oral
treatment2.
For minor, very early forms (no fever, minor pain), outpatient treatment is possible with
amoxicillin/clavulanic acid PO (dose expressed in amoxicillin): 3 g/day in 3 divided doses
for 5 to 7 days.
–Look for retained placenta, and evacuate after 24 to 48 hours of antibiotic therapy. If the
patient is haemodynamically unstable due to haemorrhage or infection, perform uterine
evacuation i mmediately.
Pelvic abscess or peritonitis
A complication of untreated puerperal endometri tis/salpingitis.
– Abdominal guarding or spasm, i leus, pelvic mass.
– Surgical treatment: laparotomy or, in case the abscess is confined to the Pouch of
Douglas, colpotomy to drain the abscess.
–Same anti biotic regimen as for postpartum endometri tis and sal pingitis.Chapter 11
228

Other infectious complications
– Absce ss after caesarean secti on.
– Lymphangitis and breast abscess (Section 11.4.3).
– Pyelonephritis (Chapte r 4, Section 4.2.7).
Note: in case of fe ver, systemati cally test for mal aria in ende mic areas.
11.4.3 Breast-related complications
Cracked nipples
– Nipple erosion and intense pain when starting to nurse . No fever (exce pt whe n associated
with lymphangitis).
– Cle an with soap and clean water be fore and after each fee ding; dry careful ly.
– Crack ed nipples are often caused by incorre ct latching onto the breast: watch the infant
nurse, and correct the posi tion if nece ssary.
Breast engorgement
– Bilateral pain 2 to 3 days after chi ldbirth; hard, pai nful breasts.
– Warm compresses (before nursing); gentle manual expression (before nursing, if the
infant cannot latch onto the overly diste nded breast or after nursing to finish emptying
the breast); more frequent nursi ng.
For manual expressi on, see Appendix 3, Section 3.2.
–Engorgement is a be nign problem that subsi des in 24 to 48 hours.
Lymphangitis (inflammation of a mi lk duct)
– Unilateral pain, 5 to 10 days after childbirth. Local inflammation, red, hot painful with no
fluctuation, high fever; axillary lymphadenopathy possible. Milk collected on a compressshows no pus.
–Empty the breast by nursing the infant frequently on the involved side. If the mother finds
nursing too painful, temporarily stop nursing on the painful side (but empty the breast
manually) and continue breastfeeding with the other breast.
– Routine anal gesia (
paracetamol PO: 3 g/day in 3 di vided doses).
Mastitis (breast infection)
– Unilateral infection, with satellite lymph node ; breast swollen, hot, red, painful, purulent
discharge from the ni pple, at times associated with feve r.
– Temporarily stop nursing on the infecte d side. Carefully expre ss all milk from the infected
breast (manual ly) and admi nister an anti biotic with anti -staphylococcal acti vity:
cloxacillin PO: 3 g/day in 3 di vided doses for at least 7 days.
– Routine anal gesia (paracetamol PO: 3 to 4 g/day in 3 to 4 di vided doses).
– Antibiotic treatment helps prevent progression to breast abscess that requires surgical
drainage. Surgical drainage of a “ripe” abscess is urgent, because an abscess can quickly
spread.
11.4.4 Urine leakage
– Look for a possible vesicovaginal fistula, especially after a difficult home birth or prolonged
labour.
–If there is a fi stula: see Chapter 7, Section 7.2.5.
– If there is no fistula, stress incontinence is likely: propose exercises to strengthen the
pelvic floor.Postpartum/postnatal period
22911

Stress incontinence is more common among grand multiparas, after a forceps or vacuum
extraction, and in cases of macrosomia. It usually disappears within 3 months with pelvic
floor exercises.
11.4.5 Psychological disorders
“The baby blues”
This syndrome has its onset wi thin days after the del ivery and lasts usual ly two we eks.
It is characterised by mood swings, crying, irritability, anxious worrying centred on the
infant, and doubts about the ability to be a “good mother”, combine d with insomnia, loss of
appetite and conce ntration probl ems.
These problems generally diminish within a few days. Reassurance, family support and
follow-up to ensure that the patient does not develop depression are usually sufficient.
Postpartum depression
Post-partum depression develops in the first several week s after childbirth; it can be severe
and is often underesti mated.
The characteristic symptoms of depression are sadness, frequent crying, loss of self-
confidence, constant concerns about the infant (or, on the contrary, a feeling of indifference),
feeling incompetent as a mother, and feelings of guilt (or even aggressive thoughts toward the
infant) combined with insomnia and loss of appetite. These symptoms last more than 2weeks
and gradual ly worsen, leading to a state of exhausti on.
The intervie w should look for possible suicidal thoughts and asse ss the mother’ s ability and
desire to take care of the infant (depression can have repercussions for the infant’s
development).
An understanding and reassuring attitude and help with daily activities by family and friends
are essential.
Antidepressant medication may be necessary (choose an antidepressant compatible with
breastfeeding, which should be continued whenever possible). See the MSF handbook,
Clinical guidelines.
Note: perinatal death is associated with increased rates of postpartum depressi on.
Postpartum psychosis
This occurs less frequently and is characterised by the onset of psychotic symptoms after
childbirth.
Symptoms include irritability, important mood swings, delusions, hallucinations, and disorganised,
bizarre and someti mes violent behaviour.
The patient should be sent to a doctor immediately. Antipsychotic treatment, and usually
hospitalisation, is necessary. See the MSF handbook, Clinical guidelines.Chapter 11
230

11.5 Contraception
Contraceptive method should be chosen based on medical indications or contra-indicationsa
and the preference of the woman, who is in the best position to know which method fits her
lifestyle.
The following clinical examinations are essential:
–For hormonal contraception : blood pressure. Combined oestrogen-progestogen contraceptives
are contra-indicated in women with hypertension but progestogen only oral contraceptives
and implants can be used.
–For an intrauterine device : speculum and digital vaginal examination. Placement of an
intrauterine device is contra-indicated in case of pelvic infection. In this situation, the device
is inserted after the infection has resolved.
For both methods, exclude pregnancy (if in doubt, perform pregnancy test).
No other laboratory testing is required for prescribing contraceptives.
11.5.1 Contraceptive methods
Breastfeeding
Breastfeeding is a temporary and effective (> 98%) method of contraception, but only if all
of the following conditions are met:
– exclusive breastfeeding of an infant less than 6 months old;
– less than 6 hour-intervals between feedings;
– continued amenorrhoea.
Hormonal contraception
There are several products that differ in terms of route of administration, composition or
duration of action (Table 11.1).
Table 11.1 – Hormonal contraception
aFor more information on contraception: World Health Organization. Medical eligibility criteria for
contraceptive use, Fourth edition, 2010.
http://www.who.int/reproductivehealth/publications/family_planning/9789241563888/en/Type Examples
Combined oestrogen-progestogen
oral contraceptivesEthinyloestradiol/lrvonorgestrel (Microgynon®,
Minidril®, etc.)
Progestogen-only contraceptives
•Oral progestogens (“minipill”)
•Progestogen injectables
•Progestogen implants
(long-acting contraception)Levonorgestrel (Microlut®, Microval®, Norgeston®,
etc.) or desogestrel
Medroxyprogesterone (Depo-Provera®, etc.)
Levonorgestrel (Jadelle®), etonogestrel (Nexplanon®),
etc.Postpartum/postnatal period
23111

Intrauterine device
This copper devi ce inserte d in the uterus provides long-term contracepti on.
Condoms
Male and female condoms, in addition to their contraceptive effect, are the only method of
protection against HIV and other sexual ly transmitted i nfections.
They should always be offered in addition to the other methods, as protection against
sexually transmitted i nfections.
Sterilisation
Sterilisation (bi lateral tubal l igation for women and vasectomy for men) is i rreversible.
If the provision of sterilisation is being considered, inquire about the national regulations
(eligibility cri teria, etc.).
Patients should be clearly informe d about the permane nt nature of sterilisation and about
possible alternatives (effective, long-acting methods like intrauterine device or contraceptive
implants). Written consent is always requi red to perform the i ntervention.
Female sterilisation can be performed during caesarean section or by minilaparotomy after
delivery.
11.5.2 For women who are breastfeeding
If any of the requirements that make breastfeeding an effective contraceptive method are
not met, offer one of these methods.
Hormonal contraception
– Oral progestoge ns should be initiate d at 6 wee ks postpartum. If, however, they are the
only available or acceptable contraceptive method, they may be started 21 days
postpartum.
– Progestogen implants and injections can be used from the sixth week postpartum.
However, if a woman cannot be seen again after 6 wee ks (e.g. nomadic populations), or if
they are the only available or acceptable contraceptive method, implants or injections
may be used as soon as the opportunity presents itself, including immediately after
delivery.
– Combined oestrogen-proge stogen oral contraceptives should be avoide d during the first
6months postpartum. If, however, they are the only available or acceptable contraceptive
method, they can be introduced sooner, but only after 6 weeks postpartum.
Intrauterine device
Intrauterine devices can be inserted either in the first 48 hours after delivery (after the third
stage of labour), or from the fourth week postpartum.
11.5.3 For women who are not breastfeeding
Hormonal contraception
Hormonal contraception is started on or after Day 21. If a woman cannot be seen again after
21 days (e.g., nomadic populations), progestogen implants or injectables may be used as
soon as the opportunity presents itself, including immediately after delivery.Chapter 11
232

Intrauterine device
As for women who are breastfee ding (Section 11.5.2).
11.5.4 Special situations
HIV infection
Condom use helps prevent HIV transmission to a partner, reinfection by other strains of the
HIV virus if the partner himself is HIV-positive, and transmission of other sexually
transmitted i nfections. HIV-posi tive patients should systemati cally use condoms.
Since condom use is not always optimal, however, using another effective contraceptive
method in addition to condoms to prevent pregnancy is recommended. Different
contraceptive methods can be use d.
See also Treatment with liver enzyme inducers, next section.
Treatment with liver enzyme inducers
For women taking rifampicin and rifabutin, some antiretrovirals (e.g. efavirenz, nevirapine)
and certain anti-epilep tics (carbamazepin e, phenytoin , phenobarb ital): use an intrauterine
device or an injectable progestoge n as liver enzyme induce rs reduce the efficacy of implants
and oral contracepti ves3.
Post-abortum
Contraception may be started immediately after abortion, with either a hormonal
contraceptive or intrauterine device if the re is no pelvic infection.
Emergency contraception
Every woman should be informed about—and, if needed, have access to—emergency
contraception:
–levonorgestrel PO (1.5 mg as a single dose), as soon as possible after unprotected or
poorly-protecte d sex (preferably within 72 hours, and up to 120 hours or 5 days after4).
There are no contra-indications to emergency contraceptive; it can be used whether a
woman is breastfeeding or not.The dose of levonorgestrel should be doubled (3 mg) in patient taking a liver enzyme
inducer
5.
or– Intrauterine device, to be inserted within 5 days after the unprotected or poorly-protected
sex.Postpartum/postnatal period
23311

References
1World Health Organization. WHO recommendations on postnatal care of the mother and
newborn. 2013.
http://www.who.int/maternal_child_adolescent/documents/postnatal-care-
recommendations/en/
2French LM, Smaill FM. Antibiotic regimens for endometritis after delivery (Review). The
Cochrane Library 2007, Issue 4.
http://apps.who.int/rhl/reviews/CD001067.pdf
3FSRH guidance Drug Interactions with Hormonal Contraception, 2011.
http://www.fsrh.org/pdfs/CEUguidancedruginteractionshormonal.pdf
4Levonorgestrel for emergency contraception. Fact sheet. UNDP/UNFPA/WHO/World Bank
Special Programme of Research, Devleopment and Research Training in Human Reproduction,
2005.http://www.who.int/reproductivehealth/publications/family_planning/e_contraception/en/
5British National Formulary. 7.3. Contraceptives. June 2014.Chapter 11
234

Chapter 12:
Termination of pregnancy on request
12.1 Care before abortion ……………………………………………………………………………….237
12.1.1 Information and counselling ……………………………………………………………237
12.1.2 History and examination …………………………………………………………………237
12.1.3 Choosing a method …………………………………………………………………………237
12.2 Medical abortion …………………………………………………………………………………….239
12.2.1 Contra-indications ………………………………………………………………………….239
12.2.2 Protocol ………………………………………………………………………………………..239
12.2.3 Patient information ………………………………………………………………………..240
12.2.4 Post-abortion visit ………………………………………………………………………….240
12.3 Surgical abortion …………………………………………………………………………………….242
12.3.1 Relative contra-indications ………………………………………………………………242
12.3.2 Equipment …………………………………………………………………………………….242
12.3.3 Technique ……………………………………………………………………………………..242
12.3.4 Patient follow-up ……………………………………………………………………………243
12.3.5 Complications ………………………………………………………………………………..243
12

12.1 Care before abortion
This chapte r describe s termination of pregnancy (ToP) for viable intrauterine pregnancies up
to 12 to 14 weeks of ge station.
Beyond 14 weeks, the conditions for ending a pregnancy and the management are different,
and are not de scribed in this manual .
12.1.1 Information and counselling
The decision of ending a pregnancy belongs to the patient. Her choice should be respected,
and there should be no judgment. The role of the health care staff is to allow her to make an
informed choice, to provide safe care and confidential environment.
Prior to the abortion an interview has to be ensured:
– Listen to the patient: reason(s) underlying the ToP request, situation, needs and concerns. – Discuss the possible alternative to ToP: keeping the baby or putting him up for adoption.– Provide information on ToP methods: description, advantages and disadvantages, follow-up.– Discuss contraception: available and suitable method after the ToP; see Chapter 11,
Section 11.5.
The staff is required to respect the confidentiality of the interview, the examination and the
procedure.
The patients’ consent for ToP needs to be clearly expressed.
12.1.2 History and examination
(including abdomi nal palpation, bi manual and speculum exami nations)
–If necessary, perform a pregnancy test to confirm pregnancy.– Estimate the gestational age (date of last menstrual period, fundal height); if necessary,
determine the age of the foetus and its location by ultrasound.
– Look for current problems (and treat accordingly): sexually transmitted infection (e.g.
abnormal vaginal discharge), vaginal bleeding, pelvic pain, fever, anaemia, etc.
– Take medical history (contra-indication to medical or surgical abortion method, contra-
indication to subsequent contraception methods).
–In rare cases where an i ntrauterine device is in pl ace, it must be removed.
12.1.3 Choosing a method
There are two methods of abortion: medical and surgical. There are advantages and
disadvantages to each method.Termination of pregnancy on re quest
23712

Table 12.1 – Comparison between medical and surgical abortion
*i.e. continuing viable pregnancy, in less than 1% of the cases with a combine d mifepristone + misoprostol
regimen.
Eleme nts that need to be considered in choosing the method are: the patient’ s preference,
contextual constraints (e.g. possibility to return for follow-up visit), the specific contra-
indications for each method, and operator expe rience.Medical abortion Surgical abortionAdvantages• Non-invasive method.
•Low infectious risk.• Immediate resul t.
• No absolute contraindication.
• An intrauterine device can be
inserted at the same time, at theend of the procedure.Disadvantages• No immediate result; requires a follow-up
visit to verify expulsion.
• Heavy bleeding and cramping as the
pregnancyis expelled.
• Bleeding often lasts longer than after
aspiration.
• Aspiration required in case of failure*.• Invasive method.
•(Low) risk of uterine perforation or
cervical laceration.
• Antibiotic prophyl axis requi red.Chapter 12
238

12.2 Medical abortion
The combined mifepristone + misoprostol regimen is more effective than misoprostol used
alone1and reduces the number of misoprostol doses needed, thus reducing its adverse
effects.
The unit where medical abortion is performed should be set up for vacuum aspiration (or for
easy referral for vacuum aspiration), should the medical method fail (ongoing pregnancy) or
a complication occur (significant bleeding or incomplete expulsion).
12.2.1 Contra-indications
– Coagulation disorders: in this case, vacuum aspiration is preferred.
– Chronic adrenal failure and severe uncontrolled asthma (for mifepristone only).
Note : mifepristone and misoprostol are not to be used for the termination of an ectopic or
molar pregnancy.
12.2.2 Protocol
The treatment includes:
– A combination of abortion medications:
mifepristone PO: 200 mg as a single dose
then, 36 to 48 hours later:
misoprostol sublingually or vaginally: 800 micrograms
Bleeding and cramping can be expected to start within 1 to 3 hours. If there is no bleeding
within 3 hours, administer additional doses of misoprostol : 400 micrograms every 3 hours
if necessary, until expulsion starts; maximum 4 additional doses.
If mifepristone is not available or contra-indicated, misoprostol alone is administered as
above.
AND
– An analgesic or a combination of analgesicsa:
ibuprofen PO: 800 mg every 8 hours (max. 2400 mg/day); start with misoprostol and
continue as needed after expulsion, up to 3 days maximum.
If needed, add:
codeine PO: 30 to 60 mg every 6 hours (max. 240 mg/day)
or
tramadol PO: 50 to 100 mg every 6 hours (max. 400 mg/day)
In case of nausea/vomiting (not routinely):
metoclopramide PO: 5 mg/dose for women < 60 kg; 10 mg/dose for women > 60 kg. The
interval between each dose should be at least 6 hours.
In practice:
Mifepristone is given under direct observation then, the woman goes home. Analgesics are
not required at this stage.
aThese doses may be used in adults and adolescents over 12 years.Termination of pregnancy on request
23912Updated: June 2017

Then, according to the conte xt:
– misoprostol is given to the woma n to take at home 48 hour s later (four 200 microgram
tablets for the first dose and one or more additional doses (two 200 microgram tablets,
maximum additional 8 tablets). In this case, the protocol should be clearly explained;
or
– the woman comes back and takes misoprostol at the health facility. Between 12 to
14 weeks, she should remain at the faci lity until complete expulsion.
In addition to mi soprostol, analgesics are provi ded.
12.2.3 Patient information
Before admi nistering medi cations, the patient should be i nforme d that:
– Medical abortion has approximately a 95% success rate. In case of failure, vacuum
aspiration wi ll be performe d.
– Mifepristone and misoprostol may have teratogenic effect (this information should be
known, in case she changes her mind after taking the drugs or if the regimen fai ls).
– Abortion starts within hours after taking the first dose of misoprostol and is usually
completed within 24 to 48 hours. Occasionally, it can take up to two weeks to complete
the aborti on.
– She will experience cramping and bleeding. This normally lasts for a few days until
abortion is completed. The heaviest bleeding occurs 2 to 5 hours after using misoprostol
and usually slows down within 24 hours and should not excee d 48 hours. Light bleeding
will last for 1 to 2 wee ks.
– Misoprostol, especially whe n several doses are given, can cause: nausea, diarrhoea, and a
fever that should not persist l onge r than 24 hours after taking the medi cation.
– Se vere pain, heavy bleeding, foul smelling discharge and feve r are dange r signs requiring
immediate medi cal attention.
– Menstrual periods will resume within 4 to 8 wee ks but fertility returns rapidly; ovulation
can occur as early as 2 weeks post-aborti on.
With regard to contraception, depending on the method chosen, the patient should be
informed that:
– Hormonal contrace ption will be started the day the mi soprostol is take n.
–An intrauterine device will be inserte d after comple te expulsion at the post-abortion visit,
provided there is no pel vic infection.
12.2.4 Post-abortion visit
A clinical consultation is routinely recommended 10 to 14 days after the administration of
misoprostol to:
–Make sure the abortion is compl ete;
– Diagnose and treat potenti al complications;
– Provid e contraception , if not done durin g the procedure. An intrauterin e devic e can be
inserted once complete abortion is confi rmed.Chapter 12
240

Confirmation that the abortion is complete is based on clinical evidence: there is a sufficient
amount of bleeding, the signs of pregnancy disappear, and the uterus returns to its normal size.
If in doubt:
– Confirm complete e vacuation by ul trasound, if available.
–Do not perform pregnancy test, as it re mains posi tive up to one month after aborti on.
In the absence of bleeding or in case of minimal bleeding, suspect a failure of abortion butalso an ectopic pregnancy.
In case of incomplete abortion, see Chapter 2, Section 2.1.3.In case of ectopic pregnancy, see Chapter 2, Section 2.2.3.In case of ongoing pregnancy, perform a vacuum aspiration ( Chapter9, Section 9.5).Termination of pregnancy on re quest
24112

12.3 Surgical abortion
Vacuum aspiration (either manual or electric) is an appropriate method of surgical abortion.
Instrumental curettage must not be used.
12.3.1 Relative contra-indications
– Purulent cervicitis and pelvic infection: delay the procedure if possible, until antibiotic
treatment has been finalized. If the procedure cannot be delayed, start antibiotic therapy
before doing the procedure .
– Coagulation disorders: risk of haemorrhage. Aspiration must be performed in a facility
where emergency surgery and blood transfusion are available.
12.3.2 Equipment
See Chapter 9, Se ction 9.5.3.
12.3.3 Technique
Follow pre cautions common to al l intrauterine procedures (Chapter 9, Se ction 9.1.1).
Patient preparation
– Start antibiotic therapy if infection is present and intervention cannot be delayed. For
antibiotic therapy, see Chapte r 9, Section 9.6.6.
– Administer misoprostol sublingually or vaginally into the posterior fornix: 400 micrograms
as a single dose, at least 3 hours before the procedure2to open the cervix and prevent
traumatic cervical dilation.
– Administer antibiotic prophylaxis: doxycycline PO, 200 mg as a single dose or azithromycin PO,
1 g as a single dose, one hour before the procedure.
– Administer oral premedication before paracervical block:
An hour before the procedure:
diazepam PO: 10 mg
A half-hour before the procedure:
paracetamol PO: 1 g
+ codeine PO: 30 mg if < 60 kg; 60 mg if > 60 kg
or
tramadol PO: 50 mg if < 60 kg; 100 mg if > 60 kg
Then, for the rest of the procedure (preparation equipment, paracervical block, dilation,
aspiration, examination of aspirated contents), see Chapter 9, Section 9.5.4.
Immediately after the procedure
An intrauterine device can be inserted (if there is no pelvic infection) if this is the
contraceptive method that the patient has chosen.Chapter 12
242

12.3.4 Patient follow-up
Immediate
– Settle the patient comfortably during the moni toring period (at l east 2 hours).
– Monitor vi tal signs and blood l oss.
– Pain manage ment: paracetamol and/or i buprofen.
– The patient can go home if the vital signs are stable, if she can walk and she has been
given the following information:
•Cramps wi ll continue for a few days.
• Bleeding wi ll last for 8 to 10 days.
• Menstrual pe riods will resume wi thin 4 to 8 we eks.
• Fertility returns rapidly; ovulation can occur as early as 2 weeks post-abortion. Begin
contraception that same day (Chapte r 11, Section 11.5).
• Personal hygi ene: cleansing with soap and water once dai ly; no vagi nal douches.
• Seek immediate medical attention in case of danger signs: severe pain or heavy
bleeding, foul sme lling discharge or fever.
Post-abortion visit
A consultation is advised 10 to 14 days after the procedure: look for signs of infection and
incomplete abortion, and check if contraception is well tolerated.
12.3.5 Complications
See Chapter 9, Se ction 9.6.6.Termination of pregnancy on re quest
24312

References
1Grossman D. Medical methods for first trime ster abortion: RHL commentary (last revised:
3 September 2004). The WHO Reproductive Health Library, Geneva. World Health
Organization.
http://apps.who.int/rhl/fertility/abortion/dgcom/en/
2World Health Organization. Safe abortion: technical and policy guidance for health systems.
Geneva, 2012.
http://www.who.int/reproductivehealth/publications/unsafe_abortion/9789241548434/en/Chapter 12
244

Appendices
1. Antenatal care card …………………………………………………………………………………….247
2. Bakri intrauterine balloon ……………………………………………………………………………249
2.1 Indication ……………………………………………………………………………………………..249
2.2 Contra-indications ………………………………………………………………………………….249
2.3 Balloon catheter placement …………………………………………………………………….249
2.4 Associated treatment ……………………………………………………………………………..250
2.5 Patient follow-up ……………………………………………………………………………………250
3. Breastfeeding …………………………………………………………………………………………….251
3.1 Breastfeeding success factors ………………………………………………………………….251
3.2 Hand expression and storage of breast milk ………………………………………………252
3.3 Administering the milk by cup or other utensil …………………………………………..252
3.4 Administering the milk by oro/nasogastric tube …………………………………………252
3.5 “Supplementary nursing” technique …………………………………………………………253
3.6 Management of feeding problems (summary) …………………………………………..254
3.7 Breastfeeding in HIV-infected women ………………………………………………………255
4. Daily amounts required for feeding………………………………………………………………256
5. Placing an oro/nasogastric tube …………………………………………………………………..258
5.1 Technique ……………………………………………………………………………………………..258
5.2 Monitoring ……………………………………………………………………………………………258
6. Postnatal care card ……………………………………………………………………………………..259

Appendix 1. Antenatal care cardAppendix 1
247!"#$%&'()*+#,*%,$-'.)+'()*+#/
!"#$
%&'#()*(+,-.&/0$ !001#–$
!"#($(%)0,1)#(*%2
3/ ,,,4/ 5/
6)7,8%$&)*9#,8%$:+'+0)$#,%$#9;(,)+/
234#(.315+( 6#-( %,'.#1$ %)
75388(.315+(9.)1/(0#&0: 6#-( %,'.#1$ %)
%#)/&5&8(0#&5+(9;(<(')/5+: 6#-( %,'.#1$ %)
=/*&/5(0#&5+(9<(')/5+(>(<(?#&1: 6#-( %,'.#1$ %)
@3-A&113&"#B&.)153)/ 6#-( %,'.#1$ %)
4%*";$.#,79%)+:,8%$&)*9#,8%$:+'+0)$#,
!/&#'3& 6#-( %)
C?D#15#/-3)/BD1#>B#A8&'D-3& 6#-( %)
!/5#D&15,'(+&#')11+&"# 6#-( %)
E5+#1(
4%*";$.#,79%)+:,8%$&)*9#,7$;)&$%)$#
F1)8)/"#0(8&.),1 6#-( %)
@&8D1#-#/5&53)/(9.1##A+G()5+#1: 6#-( %)
H&#-&1#&/(-#A53)/ 6#-( %)
=/-51,'#/5&8(#I51&A53)/ 6#-( %)
F8&A#/5&(9'&/,&8(0#834#1?: 6#-( %)
JD3-3)5)'? 6#-( %)
F)-5D&15,'(+&#')11+&"#( 6#-( %)
=/*#A53)/(9D,#1D#1&8(-#D-3-: 6#-( %)
E5+#1
<$7)0';,1)#(*%2
C?D#15#/-3)/( 6#-( %)
C#&15(03-#&-# 6#-( %)
K3&.#5#- 6#-( %)
L,.#1A,8)-3- 6#-( %)
K&5# 7#I,&88?(51&/-'355#0(3/*#A53)/ 6#-( %)
C=M(3/*#A53)/ 6#-( %)
JD38#D-? 6#-( %)
!.0)'3/&8( -,1"#1? 6#-( %)
E5+#15+($+'(';,0'%$,0'%7,+=/
%&'#$
>'#(,.$+#(%9';,8$%)*7
LLNLL<%#I5(&DD)3/5'#/5(?$('+9#,&'00)+'()*+,
LLO
LLP
LLQ

Appendix 1
248
!"#$%&"&# '()$%&"&# *+)$%&"&#$ ,#-$%&"&#$ .#-$%&"&#$
/0#1
2304&(0#&5(!"#$%$&'(%)*%+","&+-$.)''/*01"##21"
3&/4200"1*%15*6&16257"1"(6" *8&7*%001'01&%$"9
:$"1&("*72(/2#*-"&+-$* 8659
;'"$%)*-"%1$*1%$"* 8<"%$#=5&(2$"9
;'"$%)*5'>"5"($# *801"#"($=%<#"($9
?'#&$&'(* 8)'(+&$2/&(%)@*$1%(#>"1#"@*'<)&A2"9
?1"#"($%$&'(* 86"0-%)&6@*<1""6-@*$1%(#>"1#"9
B'(C2(6$&>%* 80%)"@*D"))'E9
F"/"5%
B'50)%&($#* 82#"*<%6G*0%+"*&7*(""/"/9
6075+0#5+8$#1"#"
HD0-&)&#*$"#$* 81'2$&(")D*%$*$-"*7&1#$*>&#&$9
!"#$%&'(')*+#$,-(.*-/0%12')*&#(-*,(*34
I%"5'+)'<&(* 81'2$&(")D*%$*$-"*7&1#$*>&#&$9
IJK*$"#$* 8%$*$-"*7&1#$*>&#&$9
:1&("*%(%)D#&#* 8%$*)"%#$*'(6"*0"1*$1&5"#$"19
L%0&/*5%)%1&%*$"#$* 8%$*)"%#$*'(6"*0"1*$1&5"#$"19
?1"+(%(6D*$"#$* 8&7*%001'01&%$"9
F$-"1*$"#$# *8"M+M@*<)''/*$D0"9
;"11'2#*#%)$#*N*7')&6*%6&/*'1*52)$&0)"*5&61'(2$1&"($#*
O)<"(/%P')" *86'($1%4&(/&6%$"/*&(*Q#$*$1&5"#$"19
3%)%1&%*01'0-D)%R&#* 8H?*&(*S(/*%(/*T1/*$1&5M*&7*%001'01&%$"9
3%)%1&%*621%$&>"*$1"%$5"($*
:1&(%1D*$1%6$*&(7"6$&'(*$1"%$5"($HD0-&)&#*$1"%$5"($H"R2%))D*$1%(#5&$$"/*&(7"6$&'(*$1"%$5"($*F$-"1*$1"%$5"($8#9
B)"%(*/")&>"1D*G&$* 8T1/*$1&5"#$"19
3'#A2&$'*("$#* 8S*("$#*%$*$-"*7&1#$*>&#&$9
H200)"5"($%1D*7''/
913#$0::5&(#41(#$;#-1+$)&"#+&7<#&5("=1)&>0#&5("

Appendix 2. Bakri intrauterine balloon
2.1 Indication
Postpartum hae morrhage due to ute rine atony, when uterotonics fai l to control bl eeding.
A Bakri balloon is used to reduce intrauterine bleeding and avoid haemostasis hysterectomy.
In a BEmONC facility, a Bakri balloon can be used to stabilize the patient before referring her
to a CEmONC faci lity.
2.2 Contra-indications
– Uterine rupture
– Purulent infections of the vagina, cervix or uterus
2.3 Balloon catheter placement
–Assess the need for anal gesia/anaesthesia.
– Apply anti septic sol ution (10% pol yvidone iodine) to the peri neal area.
–Remove any blood clots from the uterus (uterine expl oration).
–Insert a Fol ey catheter.
– Estimate the si ze of the uterus and record it (for moni toring).
–Insert a speculum. Insert the (uninflate d) balloon into the uterus, either manually or with
atraumatic forceps. Make sure that the enti re balloon passes the i nternal ce rvical os.
– Inflate the balloon with sterile , room tempe rature 0.9% sodium chloride, until it can be
seen in the cervix (typically, 250 to 300 ml, up to 500 ml maximum); record the volume
used).
– Apply ge ntle traction to the catheter and tape the end to the pati ent's thigh.
–Connect the drainage port to a fl uid collecting bag (urine bag) to monitor haemostasi s.
!
Appendix 2
249Balloon inserted
in the uterusTip that collects the
intrauterine bloodBlood drainage port;connect to a urine bag
Inflation port

2.4 Associated treatment
– Continuous infusion of oxytocin : 20 to 40 IU depending on the dose already administered
(maximum 60 IU total dose) in 1 litre of Ringer lactate or 0.9% sodium chloride over
8hours (42 drops/mi nute).
– Antibiotic therapy IV: ampicillin 1 g + metronidazole 500 mg or amoxicillin/clavulanic acid
1 g, every 8 hours, unti l the balloon is removed.
–Start or conti nue blood transfusion to correct anaemi a.
2.5 Patient follow-up
Hourly monitoring: vital signs, urine output, fundal height, vaginal bleeding, volume of blood
colle cted in the col lecting bag, oxygen saturation (if avai lable).
If there is no blood flowing into the collection bag but the fundal height is increasing, the
catheter may be blocke d by clots: check to make sure it is open by instilling 15 to 30 ml of
sterile 0.9% sodium chl oride.
If there is no blood flowin g into the collection bag, no vagina l flow, no increas e in fundal
height and the patient is stable, the bleeding is controlled: leave the balloon in place for
24 hours.
After 24 hours, remove half the injected volume from the balloon and check bleeding and vital
signs after 30 minutes:
–If there is no visible bleeding and the patie nt is stable, completely deflate and remove the
balloon.
– If the bleeding starts up again, re-inflate the balloon for another 6 to 8 hours and/or
conside r surgery.
If the initial tamponnade fails or the bleeding starts again while the inflated balloon is still in
place, surgical treatment is i ndicated.Appendix 2
250

Appendix 3. Breastfeeding
Exclusive breastfeeding (no food or drink othe r than breast milk) for the first 6 months is the
best choice for i nfants, regardless of the term or birth we ight.
For HIV-infecte d mothers, see Section 3.7.
If the infant is unable to suck e ffectively or at al l:
–Breast mi lk can be e xpresse d with a breast pump or by hand (Section 3.2).
–If the infant has a good swallowing reflex: the milk can then be given by cup, spoon or
syringe (Section 3.3).
– If the infant cannot swallow effectively or at all: the milk is given with a gastric tube
(Section 3.4) to prevent aspi ration and e xhausting the i nfant.
If sucking is ineffective, check for hypoglycaemia (Chapter 10, Section 10.3.5) and danger
signs (Chapter 10, Section 10.3.1).
If the child is able to suckle but the quantity of maternal milk is not sufficient, the supplemental
suckling technique offers the possibility to feed her/him with infant milk while stimulating
milk production (Section 3.5).Always make sure that any medications being taken by the mother are compatible with
breastfeeding, and if necessary, adjust the treatment accordi ngly.
3.1 Breastfeeding success factors
The factors for success in bre astfeeding are:
– Informing pregnant women about breastfeeding benefits and implementation.
– Putting the infant to the breast early, within an hour of birth.– Correct and comfortable positioning of mother and infant. Proper latch-on allows
effective sucking and reduces complications (cracks): the infant should face the mother’s
body, with the chin against her breast, the nose free and the nipple and most of theareola in the mouth.
–For women with inverted or flat nipples: use techniques to help nipple protrude (nipple
massage, use of breast pump just before the infant feeds).
– Maintaining exclusive breastfeeding (unless medically contra-indicated).
– Breastfeeding on demand at least 8 times a day (at least every 3 hours).
–Good hydration (at least 3 litres/day) and a caloric intake > 2500 kcal/day for the mother,
as these directly affect the amount of milk produced.
– Nipple care, washing with water before nursing.
–An organisation that allows the mother and infant to stay together 24 hours a day.– Help with maintaining lactation even if the mother has to be separated from her infant
(preventing milk production from stopping due to lack of stimulation).
Do not stop breastfeeding if:
–The infant has diarrhoea: explain to the mother that her milk is not causing the diarrhoea.
–The mother is sick (unless serious condition): explain to the mother that her milk is not of
poor quality because she is sick.Appendix 3
251

3.2 Hand expression and storage of breast milk
Hand expression is an alternative when a breast pump is not available. Milk is expressed
every 2 to 3 hours.
Show the mother the technique . Give her a clean cup or containe r for collecting the milk.
The containe r should be washed, boiled and rinsed with boiled water and air-dried before
each use.
Technique
–Wash hands, sit comfortably and hold the container under the breast.
– With the other hand, hold the breast up with four fingers, and place the thumb above the
areola.
– Sque eze the areola betwee n the thumb and the fingers while pressing backward toward
the rib cage.
–Express each breast for at least 5 mi nutes, alternating, unti l the milk stops fl owing.
–If the milk fails to flow, check the te chnique and apply warm compre sses to the breasts.
Feed the infant i mmediately after expressing the mi lk (by cup or gastric tube).
If the infant does not take all of the collected milk, it can be stored in a clean container in
the refrigerator (2 to 8°C) for a maximum of 24 hoursa.
Warm the milk (water bath) to body temperature for the next feeding.
3.3 Administering the milk by cup or other utensil
The milk can be admi nistered using a cup, spoon or syri nge.
Use a clean (washed, boiled or rinsed with boile d water and air-dried) container/utensil for
each feedi ng.
Technique
The mother should (with help from a carer):
– Measure out the volume of milk needed according the infant’s age and weight ( Appendix 4 ).
– Hold the infant in a half-seated or upright position on her lap.– Place the cup/spoon gently against the infant’s lower lip and touch the outside of the
upper lip with the edge of the cup.
– Tilt the cup/spoon so that the milk just reaches the infant’s lips.–Let the infant take the milk at his own pace; never pour the milk into the mouth.–Stop feeding when the infant closes the mouth and is no longer interested in feeding.
3.4 Administering the milk by oro/nasogastric tube
Indications
– Infants < 1500 g: poor sucking, limited or no coordination between sucking and
swallowing, tire rapidly.
–Infants with respiratory distress: risk of aspi ration, tire rapidly.
aManaging newborn problems: a guide for doctors, nurses, and midwives. World Health Organization. 2003.
http://www.who.int/reproductivehealth/publications/maternal_perinatal_health/9241546220/en/Appendix 3
252

–Infants in poor general condition (asphyxia, meningitis, seizures, etc.): little or no sucking,
weak refl exes.
–Infants with cleft pal ate, particularly when the cl eft is very wi de.
Placing the tube
See Appendix 5.
Feeding
Before each feedi ng:
– Check that the abdomen is not distended or painful.
– Aspirate the gastric contents to verify that the gastric tube is in the correct position and
evaluate the gastric residual:•If the residual is clear or milky and < 2 to 3 ml/kg: re-inject the residual and feed the
planned amount.
•If the residual is clear or milky and > 2 to 3 ml/kg after two consecutive feedings: re-
inject the residual and feed enough to reach the total planned amount. If the day’s
feedings should have been i ncreased, wait unti l the next day to increase the amounts.
•If the residual is bilious (yellow-gre en): do not re-inje ct the residual; give the planned
amount of milk then, reassess the residual. If the residual is still bilious: stop the
feeding, look for dange r signs (Chapte r 10, Section 10.3.1 and 10.3.3) and necrotizing
enterocolitis (blood in stools and painful abdominal distension). Insert an intravenous
line for maintenance fluid therapy, start antibiotic therapy before transferring the
infants to neonate uni t.
Administering the mi lk:
– Take a sterile or clean (washed, rinsed with boiled water and air-dried) syringe, large
enough to hold the total amount of the feeding. Remove the plunger and connect the
syringe to the conic end of the tube .
–Pour the mi lk into the syri nge, which should be he ld vertically.
–Ask the mothe r to hold the syringe 10 cm above the infant and let the milk flow through
the tube by gravi ty.
–Do not use the pl unge r of the syringe to force the mi lk down faste r.
Each feeding should last 10 to 15 mi nutes.
For the dai ly amounts requi red for feeding, see Appendix 4.
3.5 “Supplementary nursing” technique
This technique is used to maintain breastfeeding when milk production is less than the daily
amount needed by the i nfant.
It consists of giving the infant formula through a feeding tube while stimulating milk
production.
Technique
–Cut off the end of a CH8 gastric tube (1 cm from the holes) and remove the cap from the
other end.
–Attach the first end to the nipple using adhesive tape. Place the other end in the cup. The
infant should have both the ni pple and the tube in the mouth whi le nursing (Figure 1).
–The mother should hold the cup 10 cm below breast-level, so that the milk is not sucked
up too qui ckly.Appendix 3
253

The infant may need 2 or 3 days to adjust to the technique. If, for the first few days, the
infant does not take al l of the mi lk in the cup, give him the rest with a cup, spoon or syri nge.
Figure 1
“Suppleme ntary nursing” techni que
3.6 Management of feeding problems (summary)
Situation Management
Problem with breastfee ding, but
breastfeeding seems possi ble (milk
production, sucking and swal lowing
are all adequate)Give mother more advi ce, build her confi dence,
always have a member of the me dical team present
during bre astfeeding, recording obse rvations in the
infant’ s chart.
Breastfeeding with i nadequate
amount of breast milk (amount of
milk produced less than infant’sdaily requirements)• Stimulate milk production by frequent
breastfeeding (8 x/day).
•Use a breast pump and the “suppl ementary
nursing” techni que.
Ineffective sucking but good
swallowing reflex•Express the mi lk with a breast pump or by hand.
• Administe r the milk using a cup, spoon or syri nge.
Ineffective sucking and poor or noswallowing reflex •Express the mi lk with a breast pump or by hand.
• Fe ed breast mi lk via a gastric tube.!
!
!
!
Appendix 3
254

3.7 Breastfeeding in HIV-infected women
To reduce the risk of HIV transmission, mothers should receive long-term antiretroviral
therapy or for as long as they are breastfee ding.
Exclusive breastfeeding is recommended for the first 6 months of life, with gradual
weaning over one month starting at age 6 months. Stopping breastfeeding abruptly is not
recommended.
Breast milk substitute s can be used as an alternative to exclusive breastfeeding only under
the following condi tions:
– There is enough infant formula avai lable for exclusive use to age 6 months.
– The mother (or the person in charge) is able to prepare the formula under good hygiene
conditions and frequently enough to l imit the risk of diarrhoea or mal nutrition.
– There is access to a health care faci lity offering a full range of paedi atric care.Appendix 3
255

Appendix 4. Daily amounts required for feeding
Birth weight ≥ 2500 g
* Up to 220 ml/kg may be gi ven, if necessary for growth.
Birth weight 2000 g – < 2500 g
* Up to 220 ml/kg may be gi ven, if necessary for growth.
Birth weight 1500 g – < 2000 g
* Up to 220 ml/kg may be gi ven, if necessary for growth.Total (ml/kg/day) Breast milk
D1 60 8 x 23 ml
D2 80 8 x 30 ml
D3 100 8 x 38 ml
D4 120 8 x 45 ml
D5 140 8 x 53 ml
D6 160 8 x 60 ml
D7 160-180 8 x 60-68 ml
D8 and after 160-200* 8 x 60-75 ml
Total (ml/kg/day) Breast milk
D1 60 8 x 17 ml
D2 80 8 x 23 ml
D3 100 8 x 28 ml
D4 120 8 x 34 ml
D5 140 8 x 40 ml
D6 160 8 x 45 ml
D7 160-180 8 x 45-51 ml
D8 and after 160-200* 8 x 45-56 ml
Total (ml/kg/day) Breast milk
D1 60 8 x 13 ml
D2 80 8 x 18 ml
D3 100 8 x 22 ml
D4 120 8 x 26 ml
D5 140 8 x 31 ml
D6 160 8 x 35 ml
D7 160-180 8 x 35-39 ml
D8 and after 160-200* 8 x 35-44 mlAppendix 4
256

Birth weight 1250 g – < 1500 g
In principle, newborns whose birth weight is < 1500 g should receive only 10% glucose in
continuous IV infusion for the first 48 hours of life, due to the very high risk of acute
necrotising enterocol itis with rapid early e nteral nutri tion.
The table below shows how much milk and glucose to administer simultaneously by mouth,
as a last resort – that is, only when it is impossible to administer a continuous infusion and
the newborn cannot be transferred to a ne onatal care uni t.
* Up to 220 ml/kg may be gi ven, if necessary for growth.
Birth weight 1000 g – < 1250 g
* Up to 220 ml/kg may be gi ven, if necessary for growth.Total (ml/kg/day) Breast milk 10% glucose
D1 80 12 x 5 ml 12 x 4 ml
D2 100 12 x 7 ml 12 x 4 ml
D3 120 12 x 10 ml 12 x 4 ml
D4 140 12 x 14 ml 12 x 2 ml
D5 160 12 x 18 ml −
D6 160-180 12 x 18-21 ml −
D7 160-200 12 x 18-23 ml −
D8 and after 160-200* 12 x 18-23 ml −
Total (ml/kg/day) Breast milk 10% glucose
D1 80 12 x 5 ml 12 x 3 ml
D2 100 12 x 6 ml 12 x 3 ml
D3 120 12 x 8 ml 12 x 3 ml
D4 140 12 x 11 ml 12 x 2 ml
D5 160 12 x 15 ml −
D6 160-180 12 x 15-17 ml −
D7 160-200 12 x 15-19 ml −
D8 and after 160-200* 12 x 15-19 ml −Appendix 4
257

Appendix 5. Placing an oro/nasogastric tube
Gastric tube s must always be used with great caution. There is a risk of aspiration if the tube
is used incorrectly.
If possible, use the orogastric route rather than the nasogastric route in cases of respiratory
distress or weight below 1500 g. Both nostrils must remain unobstructed for effective
breathing.
5.1 Technique
–Choose a CH6 or CH8 tube, depending on the size of the infant’ s nostrils. The tube must
not compl etely block the ope ning of the nostri l.
– Measure the distance from the mouth (oro-) or bridge of the nose (naso-) to the tragus of
the ear, and then the distance from the tragus of the ear to the xyphoid process of the
sternum. Mark this i nsertion l ength on the tube with a pe n.
– Lubricate the tube with wate r. Hold the infant’s head firmly to prevent injury. Insert the
tube in a continuous motion to the pen mark.
– Se cure the tube with adhe sive tape.
–Check for correct tube pl acement:
1) aspirate the stomach contents
AND
2) inject 2 ml of air into the stomach via the tube . Place a stethoscope on the abdomen
to listen for the noise of the air in the stomach.
If there is any doubt about the tube posi tion, withdraw the tube and start ove r.
Intrapulmonary admi nistration of the l iquid contents can be fatal .
To feed, connect a 20-ml syringe, without its plunger, to the tube (tulip) and allow the milk
in the syringe to flow by gravity (Appendix 3, Section 3.4).
Rinse the tube with a few ml of 0.9% sodium chl oride after each use .
5.2 Monitoring
The tube position should always be checked before administering any liquid or medication;
check the position of the reference mark, check that aspiration brings up gastric liquid, and
inject air into the stomach. If not correctly positioned, re-insert the tube and verify that it is
correctly posi tioned.
Replace the tube every 3 days, switching nostrils with each new tube, or sooner if the tube
becomes clogged. Evaluate if tube is sti ll necessary before repl acing.Appendix 5
258

Appendix 6. Postnatal care cardAppendix 6
259!"#$%&$&'()&*+()&*,(%-.
!"#$%&'()*+, -#$',
./#0%(#, 1#/#, 2*3/4%3&,
5#4')36)&'"4)0%7%4)8%6)&34)(%79:#/;'(<, 2;',2((/'77,
5#4')36)(%79:#/;')6/3$)1-=, =#$')43)2-=, >'7) -3
5#4')36)('?%0'/+, @A??)4'/$) 1/'B4'/$
C&6#&4D7)&#$', E%/4:)F'%;:4,
!"#$%&'($)*+,($-)$.((/(/$-.$,+)($&#$%012-*1($3-'24)5$0)($+$)(*+'+2($678$,+'/$2&$'(,&'/$-.#+.2$&3)('9+2-&.):
!*+/0"1#(2*+3%&%)0+#( !2&$3($#-11(/$&.1;$-#$.&$+.2(.+2+1$,+'/$+9+-1+31(:
G%0')*%/4:) >'7) -A$*'/, -3
H4%??)*%/4:)8*3/&)('#(< >'7) -A$*'/, -3
45#+*/&$0"%#("*(+6&70%&$0"%#. -'3&#4#?)('#4:)8I)J)$3&4:< >'7) -A$*'/, -3
C&6#&4)('#4:)8J)$3&4:)B)J)+'#/< >'7) -A$*'/, -3
K%79#//%#;'L#*3/4%3& >'7) -A$*'/, -3
!*"5'+7#(,1*0%3($80#(2*+3%&%)9(&%,(,+'0/+*9
2&#'$%#)8%&(%9#4')M*)%6)N&3F&<
M+O'/4'&7%3&LO/'BL'9?#$O7%#)
2&4'O#/4A$):#'$3//:#;'
1/3?3&;'(L3*74/A94'()?#*3A/
K#?O/'7'&4#4%3&)8*/''9:P)34:'/<
=#'7#/'#&)7'94%3&
C&74/A$'&4#?)'"4/#94%3&
1?#9'&4#)8&3/$#?L$#&A#?)('?%0'/+<
!O%7%343$+
1'/%&'#?)?#9'/#4%3&)84'#/<
1374O#/4A$):#'$3//:#;')
C&6'94%3&)8OA'/O'/#?)7'O7%7<)
Q4:'/,
:+,0)&'(80#$"*9 $!2&$3($#-11(/$&.1;$-#$.&$+.2(.+2+1$,+'/$+9+-1+31(:
M+O'/4'&7%3&) >'7) -3 !O%?'O7+ >'7) -3
M'#/4)(%7'#7' >'7) -3 MCR)%&6'94%3& >'7) -3
5%#*'4'7 >'7) -3 SA*'/9A?37%7 >'7) -3
2*(3$%&#?)7A/;'/+ >'7) -3 Q4:'/
H'"A#??+)4/#&7$%44'(
%&6'94%3& >'7) -3@%74A?#)O/'7'&4L$#&#;'$'&4-'F*3/&)/'6'//'()63/)63??3FBAO)0#99%&'7)#&();/3F4:)$3&%43/%&;
-#$')36)9?%&%9)&'F*3/&)%7)/'6'//'()43,

Appendix 6
260
!"##$%&'())*'(
+(,&('-.*'(
/0-(,1-%2 3#04*03.15-6%7-(,#8"#910 :
!'(-).)%2 (;8;%10<(3.1#06%(08#'8(,(0. :
=.('10(%105#"*.1#0%2 "(5("%#<%<*0$*) :
>#371-%2 3#"#*'%-0$%?*-0.1.@ :
A(-"108%2 1<%"-3('-.1#0%#'%(&1)1#.#,@%#'%BC)(3.1#0 :
D-))108%*'10(%-0$%).##"%0#',-""@
E#.7('C10<-0.%10.('-3.1#0
!"#$%&#'%(F
+(.-0*)%5-3310(%2 -33#'$108%.#%)37($*"( :
G(''#*)%)-".)%H%<#"13%-31$%#'%,*".1&"(%,13'#0*.'1(0.)%
I(.10#"%251.-,10%/:
>-9#'-.#'@%.().%'()*".)%2 1<%-0@:
+(,&('-.*'(
A(-'.%'-.(
I()&1'-.#'@%'-.(
J(187.
/&&(-'-03(F%3#"#*'6%9'(-.71086%-3.151.@
A(-$C.#C.#(%(K-,%2 1<%0#.%$#0(%-.%91'.7 :
B#'$%3#0$1.1#0
G(($108%2 #9)('5( :LM(187.%8-10
D-))108%*'10(%-0$%).##"%0#',-""@
!"#$%&#'%() 21<%0#.%$#0(%-.%91'.7:F
+(.'-3@3"10(%(@(%#10.,(0.
N1.-,10%O
P("<%-0$%10<-0.%3-'(
Q-08('%)180)%<#'%,#.7('%-0$%10<-0.
!'(-).<(($108%2 (K3"*)15(%9'(-)<(($1086%)*&&#'.6%(.3 ;:
B#0.'-3(&.1#0
I()*,&.1#0%#<%,(0)()%-0$%)(K*-"%-3.151.@
R0<-0.%8'#M.7%,#01.#'108%-0$%5-3310-.1#0)*(%)+,(,%)2SCT%$-@)%&#).%$("15('@: -'.)+,(,%)2UCV%M((W)%&#).C$("15('@:
/'0$'%) 210%3-)(%#<%,*".1&"(%91'.7)6%*)(%-%)(&-'-.(%DXB%3-'$%.#%'(3#'$%10<-0.%#9)('5-.1#0):
1#$2%3)#.45$%,6'76%3#"
Q#)()%#<%5-3310()% 2%A(&-.1.1)%!Y6%!BZ6%D#"1#%Y:
[.7('

Index
A
Abortion, incomplete ………………………………………………………………………………………………..34
Abortion, induced, information and counseling …………………………………………………………..237
Abortion, induced, medical method …………………………………………………………………………..239
Abortion, induced, surgical method …………………………………………………………………………..242
Abortion, ongoing …………………………………………………………………………………………………….34
Abortion, septic ………………………………………………………………………………………………………..34
Abortion, spontaneous ………………………………………………………………………………………………33
Abortion, threatened ………………………………………………………………………………………………..33
Abruptio placentae…………………………………………………………………………………………………..48
Active pulmonary tuberculosis…………………………………………………………………………………216Amniotic sac…………………………………………………………………………………………………………….87Amoebiasis, treatment (mother) …………………………………………………………………………………65
Anaemia, treatment (mother) …………………………………………………………………………………….59
Anaemia, prevalence …………………………………………………………………………………………………24
Anaemia, prevention …………………………………………………………………………………………………24
Anaemia, screening …………………………………………………………………………………………………..22
Ancylostomiasis, treatment (mother) ………………………………………………………………………….65
Antenatal care card…………………………………………………………………………………………………247Antenatal consultations…………………………………………………………………………………………….19Antibioprophylaxis, caesarean section ………………………………………………………………………131
Antibioprophylaxis, manual exploration of the uterus …………………………………………………..81
Antibioprophylaxis, surgical ToP ……………………………………………………………………………….242
Antibiotic therapy, endometritis ……………………………………………………………………………….191
Antibiotic therapy, newborn …………………………………………………………………………………….210
Antibiotic therapy, perforation of the uterus ………………………………………………………………191
Antibiotic therapy, peritonitis …………………………………………………………………………………..191
Antibiotic therapy, postpartum genital infections ……………………………………………………….228
Antibiotic therapy, premature rupture of membranes …………………………………………………..76
Antibiotic therapy, salpingitis …………………………………………………………………………………..191
Antibiotic therapy, septic abortion ……………………………………………………………………………..34
Antimalarials, injectable ……………………………………………………………………………………………63
Antimalarials, oral ……………………………………………………………………………………………………63
Apgar score……………………………………………………………………………………………………………201Artemisinin-based combination therapy……………………………………………………………………..63Artificial rupture of membranes………………………………………………………………………….96, 143Ascariasis, treatment (mother) …………………………………………………………………………………..65
B
Baby blues……………………………………………………………………………………………………………..230
Bacteriuria, asymptomatic, treatment (mother) ……………………………………………………………61
Bakri balloon…………………………………………………………………………………………………..169, 249
Bandlring mechani sm……………………………………………………………………………………………….51
BCG…………………………………………………………………………………………………………204, 216, 227
BEmONC………………………………………………………………………………………………………………….26Birth, kit ………………………………………………………………………………………………………………….26
Birth, plan ………………………………………………………………………………………………………………..26
Birth, preparation …………………………………………………………………………………………………….26Index
261

Bishop score …………………………………………………………………………………………………………..143
Bleeding, during pregnancy ………………………………………………………..33, 36, 38, 41, 45, 48, 50
Bracht, manoeuvre ………………………………………………………………………………………………….124
Breast milk, administration ………………………………………………………………………………………252
Breast milk, hand expression ………………………………………………………………………………….. .252
Breast milk, storage……………………………………………………………………………………………….. 252
Breast milk, “supplementary nursing” technique …………………………………………………………253
Breast, engorgement ………………………………………………………………………………………………229
Breastfeeding…………………………………………………………………………………………………………251
Breech, complete …………………………………………………………………………………………….119, 128
Breech, footling ………………………………………………………………………………………………………119
Breech, frank …………………………………………………………………………………………………..119, 128
Breech, head entrapment ………………………………………………………………………………………..123
Breech, obstructed shoulder …………………………………………………………………………………….122
Breech, presentation ……………………………………………………………………………………………….119
Breech, total extraction …………………………………………………………………………………………..128
Brow presentation………………………………………………………………………………………………….159
C
Cabergoline………………………………………………………………………………………………………80, 224
Caesarean se ction…………………………………………………………………………………………………..130
Calcium, carbonate …………………………………………………………………………………………………..25
Calcium, gluconate ……………………………………………………………………………………………………70
Calcium, supplementation …………………………………………………………………………………….25, 72
CEmONC………………………………………………………………………………………………………………….26Cervicitis………………………………………………………………………………………………………………….40Chickenpox, treatment (mother) ………………………………………………………………………………..66
Chlamydial i nfection, newborn …………………………………………………………………………………214
Coagulation di sorders…………………………………………………………………………………48, 168, 170
Colecalciferol……………………………………………………………………………………………………………25Combined oestrogen-progestogen contracepti ves……………………………………………………..231
Condoms……………………………………………………………………………………………………………….232Contraception, emergency ……………………………………………………………………………………….233
Contraception, methods …………………………………………………………………………………..231, 232
Contraception, post ToP ……………………………………………………………………………………240, 242
Cord, care……………………………………………………………………………………………………….201, 219
Cord, clamping ………………………………………………………………………………………………….92, 201
Cord, nuchal…………………………………………………………………………………………………………..100
Cord, prolapsed ………………………………………………………………………………………………………..98
Cracked ni pples………………………………………………………………………………………………………229
Cranioclasis……………………………………………………………………………………………………………196Craniotomy……………………………………………………………………………………………………………195Culdocentesis…………………………………………………………………………………………………………..37Curettage, digital……………………………………………………………………………………………………184
Curettage, instrumental …………………………………………………………………………………………..189
Cystitis, treatment (mother) ……………………………………………………………………………………….61
D
Decapitation…………………………………………………………………………………………………………..197Deinfibulation………………………………………………………………………………………………………..115Delivery due date……………………………………………………………………………………………………..20Delivery, breech ……………………………………………………………………………………………………..120
Delivery, destructive ……………………………………………………………………………………………….193Index
262

Delivery, foetus ………………………………………………………………………………………………………..89
Delivery, instrumental ……………………………………………………………………………………………..101
Delivery, normal ……………………………………………………………………………………………………….85
Delivery, preterm ……………………………………………………………………………………………………..79
Delivery, preterm, threatened …………………………………………………………………………………….78
Delivery, twins ………………………………………………………………………………………………………..126
Depression, postpartum ………………………………………………………………………………………….230
Destructive delivery………………………………………………………………………………………………..193
Dexamethasone……………………………………………………………………………………………………….77Dinoprostone, intrauterine foetal death ………………………………………………………………………80
Dinoprostone, labour induction ………………………………………………………………………………..142
Dystocia, dynamic …………………………………………………………………………………………………..137
Dystocia, mecanical ………………………………………………………………………………………………..137
Dystocia, shoulder …………………………………………………………………………………………………..147
E
Eclampsia………………………………………………………………………………………………………………..73Ectopic pregnancy…………………………………………………………………………………………………….36Ectropion…………………………………………………………………………………………………………………33Embryotomy………………………………………………………………………………………………………….193Engagement…………………………………………………………………………………………………………….88Episiotomy………………………………………………………………………………………………………109, 112Ergocalciferol…………………………………………………………………………………………………………..25
F
Face prese ntation…………………………………………………………………………………………………..156
Feeding of the newborn……………………………………………………………………..203, 218, 253, 256Ferrous sulfate/folic acid, treatment of anaemia ………………………………………………………….59
Ferrous sulfate/folic acid, prevention of anaemia …………………………………………………………24
Fever, antipyretics (mother) ……………………………………………………………………………………….60
Fistulae………………………………………………………………………………………………………………….141Foetal, heart rate ……………………………………………………………………………………………………..86
Foetal, lung maturation …………………………………………………………………………………………….78
Forceps………………………………………………………………………………………………………………….104Functional bleeding…………………………………………………………………………………………………..41Fundal height, measurement ……………………………………………………………………………………..21
G
Genital muti lations………………………………………………………………………………………………….115
Gestational age, estimation ……………………………………………………………………………………….20
Gonococcal infection, newborn …………………………………………………………………………203, 214
Gonococcal infection, treatment (mother) …………………………………………………………………..61
H
Haematocele……………………………………………………………………………………………………………36Haematoperitoneum………………………………………………………………………………………………..36Haematosalpinx……………………………………………………………………………………………………….36Haemorrhage, postpartum, early ……………………………………………………………………………..168
Haemorrhage, postpartum, late ……………………………………………………………………………….172
Haemorrhage, pregnancy …………………………………………………………..33, 36, 38, 41, 45, 48, 50
Haemorrhagic disease of the newborn………………………………………………………………………203Hepatitis B, maternal ………………………………………………………………………………………………..66
Hepatitis B, newborn ……………………………………………………………………………66, 204, 215, 227Index
263

Hepatitis E, maternal ……………………………………………………………………………………………….66
Herpes genital , treatment (mother) …………………………………………………………………………….66
Herpes, newborn …………………………………………………………………………………………………….215
HIV infection, ante-partum care …………………………………………………………………………………67
HIV infection, breastfeeding …………………………………………………………………………………….255
HIV infection, contraception …………………………………………………………………………………….233
HIV infection, per-partum care …………………………………………………………………………………..67
HIV infection, PMTCT ……………………………………………………………………………………….203, 215
HIV infection, postpartum care …………………………………………………………………………………..67
HIV infection, screening ……………………………………………………………………………………….21, 23
Hormonal contraception…………………………………………………………………………………..231, 232
Hydatidiform mole……………………………………………………………………………………………………38Hydralazine, injectable ………………………………………………………………………………………………71
Hypertension, chronic ……………………………………………………………………………………………….68
Hypertension, pregnancy-induced ………………………………………………………………………………68
Hypoglycaemia, newborn …………………………………………………………………………………………211
I
mplants…………………………………………………………………………………………………………………231Intrauterine device…………………………………………………………………………………………..232, 233Intrauterine foetal death…………………………………………………………………………………………..80Intrauterine procedures…………………………………………………………………………………………..181
J
Jarisch-Herxheimer reacti on………………………………………………………………………………………61
Jaundice, newborn ………………………………………………………………………………………………….212
K
Kangaroo care ……………………………………………………………………………………………………….217
L
Labetalol, injectable ………………………………………………………………………………………………….71
Labetalol, oral ………………………………………………………………………………………………………….69
Labour, induction ……………………………………………………………………………………………………142
Labour, monitoring …………………………………………………………………………………………………..93
Labour, obstructed ………………………………………………………………………………………………….140
Labour, prolonged …………………………………………………………………………………………………..137
Labour, third stage, active management ……………………………………………………………………165
Labour, third stage, normal ……………………………………………………………………………………..165
Labour, third stage, prevention of postpartum haemorrhage ……………………………………….165
Lactation……………………………………………………………………………………………………………….223Lochia …………………………………………………………………………………………………………………..223Lovset, manoeuvre ………………………………………………………………………………………………….122
Low birth weight…………………………………………………………………………………………………….217Lymphangitis………………………………………………………………………………………………………….229
M
Magnesium sul fate………………………………………………………………………………………………70, 73
Malaria, intermittent preventive treatment ………………………………………………………………….24
Malaria, screening ……………………………………………………………………………………………….21, 23
Malaria, treatment (mother) …………………………………………………………………………………63, 64
Malnutrition, maternal ……………………………………………………………………………………………..25
Manoeuvre, Bracht …………………………………………………………………………………………………124
Manoeuvre, Lovset ………………………………………………………………………………………………….122Index
264

Manoeuvre, Mauriceau …………………………………………………………………………………………..124
Manoeuvre, McRoberts …………………………………………………………………………………………..147
Manoeuvre, Rubin …………………………………………………………………………………………………..147
Manoeuvre, Suzor …………………………………………………………………………………………………..123
Manoeuvre, Wood ………………………………………………………………………………………………….147
Manual vacuum aspiration………………………………………………………………………………………185
Mastitis…………………………………………………………………………………………………………………229Mauriceau, manoeuvre……………………………………………………………………………………………124McRoberts, manoeuvre ……………………………………………………………………………………………147
Meconium………………………………………………………………………………………………………….86, 88Membranes, artificial rupture ……………………………………………………………………………..96, 143
Membranes, premature rupture …………………………………………………………………………………76
Membranes, stripping ……………………………………………………………………………………………..143
Meningitis, treatment (mother) ………………………………………………………………………………….60
Menstrual period, return ………………………………………………………………………………………..223
Methyldopa……………………………………………………………………………………………………………..69Methylergometrine…………………………………………………………………………………………………169Mifepristone, intrauterine foetal death ……………………………………………………………………….80
Mifepristone, ToP……………………………………………………………………………………………………239Misoprostol, dilation before MVA ……………………………………………………………………………..186
Misoprostol, incomplete abortion ……………………………………………………………………………….35
Misoprostol, intrauterine foetal death ………………………………………………………………………..80
Misoprostol, labour induction …………………………………………………………………………………..142
Misoprostol, postpartum haemorrhage …………………………………………………………………….169
Misoprostol, ToP …………………………………………………………………………………………….239, 242
Molar pregnancy………………………………………………………………………………………………………38Multiple micronutriments………………………………………………………………………………………….24
N
Neonatal i nfection, asymptomatic …………………………………………………………………………….210
Neonatal infection, symptomatic ………………………………………………………………………………209
Newborn, antibacterial dosing …………………………………………………………………………………210
Newborn, asymptomatic infection …………………………………………………………………………….210
Newborn, chlamydial infection …………………………………………………………………………………214
Newborn, danger signs ……………………………………………………………………………………………208
Newborn, feeding ………………………………………………………………………………203, 218, 253, 256
Newborn, gonococcal infection ………………………………………………………………………….203, 214
Newborn, prevention of haemorrhagic disease …………………………………………………………..203
Newborn, hepatitis B ……………………………………………………………………………66, 204, 215, 227
Newborn, herpes …………………………………………………………………………………………………….215
Newborn, hypoglycaemia ………………………………………………………………………………………..211
Newborn, jaundice ………………………………………………………………………………………………….212
Newborn, low birth weight ………………………………………………………………………………………217
Newborn, postnatal consultations …………………………………………………………………………….227
Newborn, respiratory distress …………………………………………………………………………………..208
Newborn, resuscitation ……………………………………………………………………………………………205
Newborn, routine care ……………………………………………………………………………………..201, 219
Newborn, routine examination ………………………………………………………………………….201, 202
Newborn, seizures …………………………………………………………………………………………………..207
Newborn, symptomatic infection ………………………………………………………………………………209
Newborn, syphilis ……………………………………………………………………………………………………214
Newborn, thermoregulation …………………………………………………………………………………….203
Newborn, vaccinations ……………………………………………………………………………………..204, 227
Nifedipine, oral ………………………………………………………………………………………………………..78Index
265

O
Oro/nasogastric tube ……………………………………………………………………………………….252, 258
Oxytocin, caesarean section ……………………………………………………………………………..131, 146
Oxytocin, dynamic dystocia ……………………………………………………………………………………..146
Oxytocin, labour induction ………………………………………………………………………………..145, 146
Oxytocin, molar pregnancy ………………………………………………………………………………………..38
Oxytocin, postpartum haemorrhage …………………………………………………………………..146, 169
Oxytocin, prevention of postpartum haemorrhage ………………………………………………146, 165
Oxytocin, twin delivery …………………………………………………………………………………………….127
P
Paracervical bl ock ……………………………………………………………………………………………186, 242
Partograph………………………………………………………………………………………………………………93
Perine um, repair …………………………………………………………………………………………………….111
Phytomenadione, newborn ……………………………………………………………………………….203, 227
Phytomenadione, supplementation (mother) ……………………………………………………………….25
Placenta, examination ……………………………………………………………………………………………..167
Placenta, manual removal ………………………………………………………………………………..169, 182
Placenta, praevia ………………………………………………………………………………………………………45
Placenta, retained ………………………………………………………………………………………….. .168, 169
Placental abrupti on…………………………………………………………………………………………………..48
Polio oral ………………………………………………………………………………………………………..204, 227
Polyhydramnios, acute………………………………………………………………………………………………75
Polyhydramnios, chronic……………………………………………………………………………………………75
Postnatal care card …………………………………………………………………………………………………259
Postnatal consul tations, mother……………………………………………………………………………….226
Postnatal consul tations, newborn …………………………………………………………………………….227
Postpartum, complications ………………………………………………………………………………………228
Postpartum, depression …………………………………………………………………………………………..230
Postpartum, genital infections ………………………………………………………………………………….228
Postpartum, monitoring …………………………………………………………………………………………….95
Postpartum, mother care …………………………………………………………………………………………224
Postpartum, psychosis …………………………………………………………………………………………….230
Pouch of Dougl as, puncture ……………………………………………………………………………………….37
Pre-eclampsia…………………………………………………………………………………………………………..68Pre-eclampsia, secondary prophylaxis …………………………………………………………………………72
Pregnancy, cervical …………………………………………………………………………………………………..36
Pregnangy, complications ………………………………………………………………………………………….27
Pregnancy, ectopic ……………………………………………………………………………………………………36
Pregnancy, molar ……………………………………………………………………………………………………..38
Pregnancy, termination on request, information and counseling …………………………………..237
Pregnancy, termination on request, medical method …………………………………………………..239
Pregnancy, termination on request, surgical method …………………………………………………..242
Pregnancy, test………………………………………………………………………………..17, 36, 38, 237, 241
Pregnancy, tubal………………………………………………………………………………………………………36
Pregnancy, twins…………………………………………………………………………………………………….126
Premature rupture of membranes ……………………………………………………………………………..76
Presentation, brow…………………………………………………………………………………………………159
Presentation, face…………………………………………………………………………………………………..156
Preterm del ivery………………………………………………………………………………………………………79
Progestogens …………………………………………………………………………………………………………231Psychosis, postpartum …………………………………………………………………………………………….230
Puerperal i nfections………………………………………………………………………………………………..228
Pyelonephritis, treatment (mother) …………………………………………………………………………….62Index
266

R
Repair, anal sphincter ……………………………………………………………………………………………..112
Repair, perineum ……………………………………………………………………………………………..111, 112
Repair, rectal mucosa ……………………………………………………………………………………………..113
Repair, vulva ………………………………………………………………………………………………………….112
Respiratory distress, newborn ………………………………………………………………………………….208
Resuscitation, newborn ……………………………………………………………………………………………205
Retinol…………………………………………………………………………………………………………………..226Rubin, manoeuvre …………………………………………………………………………………………………..147
Rupture of membranes, artificial …………………………………………………………………………96, 143
Rupture of membranes, premature …………………………………………………………………………….76
S
Salbutamol………………………………………………………………………………………………………………78Seizures, newborn …………………………………………………………………………………………………..207
Shigellosis, treatment (mother) ………………………………………………………………………………….60
Shoulder, dystocia …………………………………………………………………………………………………..147
Shoulder, presentation …………………………………………………………………………………………….149
Sulfadoxine/pyrimethamine………………………………………………………………………………………24Suzor, manoeuvre …………………………………………………………………………………………………..123
Symphysiotomy………………………………………………………………………………………………………105Syphilis, newborn ……………………………………………………………………………………………………214
Syphilis, screening …………………………………………………………………………………………………….21
Syphilis, treatment (mother) ………………………………………………………………………………………61
T
Tear, anal sphincter ………………………………………………………………………………………….111, 112
Tear, cervix …………………………………………………………………………………………………………….176
Tear, perineum ………………………………………………………………………………………………..111, 112
Tear, rectal mucosa ………………………………………………………………………………………….111, 113
Tear, vagina …………………………………………………………………………………………………………..176
Tear, vulva ………………………………………………………………………………………………………111, 112
Tetanus vaccination, prenatal …………………………………………………………………………………….23
Tetanus vaccination, septic abortion …………………………………………………………………………..34
Thromboprophylaxis, caesarean section ……………………………………………………………………131
Transverse lie…………………………………………………………………………………………………………149Trendelenburg position……………………………………………………………………………………………..99Twin, delivery …………………………………………………………………………………………………………126
Twin, pregnancy ……………………………………………………………………………………………………..126
Typhoid fever, treatment (mother) ……………………………………………………………………………..60
U
Ultrasound………………………………………………………………………17, 20, 33, 36, 46, 80, 237, 241
Urinary tract i nfection, screening ………………………………………………………………………….22, 23
Urinary tract i nfection, treatment (mother) ……………………………………………………………61, 62
Urine leakage…………………………………………………………………………………………………………229
Uterine, involution ………………………………………………………………………………………………….223
Uterine, rupture……………………………………………………………………………………………………….50
Uterus, abnormally large …………………………………………………………………………………………..74
Uterus, atony………………………………………………………………………………………………….168, 169
Uterus, exploration ………………………………………………………………………………………….169, 183
Uterus, inversion …………………………………………………………………………………………………….173
Uterus, involution ……………………………………………………………………………………………………223
Uterus, perforation …………………………………………………………………………………………………191
Uterus, rupture………………………………………………………………………………………………………..50Index
267

V
Vaccinations, newborn ……………………………………………………………………………………..204, 227
Vacuum extraction………………………………………………………………………………………………….101
Version, external …………………………………………………………………………………………………….152
Version, internal ……………………………………………………………………………………………………..154
Vitamin D, supplementation (mother) …………………………………………………………………………25
Vitamin K 1, newborn ………………………………………………………………………………………..203, 227
Vitamine K 1, supplementation (mother) ………………………………………………………………………25
W
Wood, manoeuvre ………………………………………………………………………………………………….147Index
268

In the same collection
Clinical guidelines – diagnosis and treatment manual
English, French, Spani sh
Essential drugs – practical guidelines
English, French, Spani sh, Arabic
Management of a measles epidemic
English, French
Tuberculosis
English, French
Public health engineering
English onl y
Rapid health assessment of refugee or displaced populations
English onl y

Belgium Médecins Sans Fronti ères/Artse n Zonder Grenzen
Rue Dupréstraat 94, 1090 Bruxelles/Brussel
Tel.: +32 (0)2 474 74 74Fax: +32 (0)2 474 75 75E-mail: info@msf.be
France Médecins Sans Fronti ères
8 rue Saint-Sabin, 75544 Paris cedex 11Tel.: +33 (0)1 40 21 29 29Fax: +33 (0)1 48 06 68 68E-mail: office@paris.msf.org
Netherlands Artsen Zonder Gre nzen
Plantage Mi ddenlaan 14, 1018 DD Amsterdam
Tel.: +31 (0)20 52 08 700Fax: +31 (0)20 62 05 170E-mail: offi ce@amsterdam.msf.org
Spain Medicos Sin FronterasNou de la Rambla 26, 08001 BarcelonaTel.: +34 933 046 100Fax: +34 933 046 102E-mail: oficina@barcelona.msf.org
Switzerland Médecins Sans Fronti ères
78 rue de Lausanne – Case postale 116 – 1211 Genève 27Tel.: +41 (0)22 849 84 84Fax: +41 (0)22 849 84 88E-mail: office-gva@geneva.msf.org
Achevé d’ imprimer en France par ISI, 93210 La Pl aine Saint-Denis
Janvier 2015