MANAGEMENT GUIDELINE ON

SELECTED TOPICS IN

OBSTETRICS AND GYNECOLOGY

First edition

Department of Obstetrics and

Gynecology
Faculty of Medicine
Addis Ababa University
Feb, 2004

1
Management Guideline on Selected Topics in Obstetrics and Gynecology
Feb, 2004
Copy right
Department of obstetrics and gynecology
Faculty of medicine
Addis Ababa University

2
Contributors

3
 ACKNOWLEDGEMENT

The document is the product of the unswerving commitment of members of the

department of Obstetrics and gynecology and all Postgraduate students who painstakingly
prepared each topic using evidence based literature. Each topic has been extensively
commented upon in department management session in the presence of all the staffs and
post graduate students department. Thus this document is the product of many hours of
work by many committed individuals. Although one can not praise oneself the effort need
to be appreciated.

The department would like to appreciate also W/o Zenebech Medhane, secretary of the
department, for her untiring secretarial help in writing and rewriting each topic. Our
Gratitude also goes to Dr. Eyob Kamil, Head Addis Ababa city administration health
bureau and Care Ethiopia for the interest they shown in this document, which has been a
driving force to complete this document

4
FOREWARD

Reproductive medicine has become an ever-expanding field. With technological

advancement, large research out put and demand for evidence based medical practice,
whether a beginner in the field or a busy practitioner often faces difficulty accessing
concrete information on management standards, options or recommendations. Local
guidelines can obviate this problem and make common language in patient care feasible
in a given institution. Therefore the need for development of such a management
guideline is understandable.

More than a decade back similar but less elaborate guideline on few topics has been
prepared in the department in hand out form but has not been updated then after. The
current preparation contains more topics and enjoys the opportunity to appear in book-let
form.

It is the departments hope that it would evolve into a book in foreseeable future. The
department also believes that the guideline will create understanding and be useful to
patient care.

Readers comments emerging from practical application are most welcome..

5
Table of contents

Antenatal Care............................................................................................................... 11
Number And Frequency Of Visits: ................................................................................ 15
Timing Of ANC Visits And Provision Of Care .............................................................. 15

Ante Partum Fetal Well Being Evaluation ..................................................................... 17

Indications ..................................................................................................................... 17
Antepartum Surveillance Techniques: ........................................................................... 17

Non-Reassuring Fetal Heart Rate Pattern(Nrfhrp).Fetal Distress ................................ 22

Management Of Labor And Delivery ............................................................................ 27

Definition Of Normal Labor .......................................................................................... 27
Diagnostic Criteria ........................................................................................................ 27
Management During 1st Stage........................................................................................ 28
Management During 2nd Stage ....................................................................................... 31
Management Of 3rd And 4th Stage.................................................................................. 34
Postnatal Care And Observation Before Discharge ........................................................ 36

Induction And Augmentation Of Labor ......................................................................... 38

Indications ..................................................................................................................... 38
Risks And Complications Of Induction ......................................................................... 39
Preconditions For Induction........................................................................................... 40
Methods Of Induction.................................................................................................... 40
Induction Procedure Using Oxytocin ............................................................................. 42

Augmentation Of Labor................................................................................................. 44

MANAGEMENT OF LABOUR ABNORMALITIES ................................................... 46

Labor Abnormalities...................................................................................................... 47
Latent Phase Of First Stage Of Labor. ........................................................................... 47
Active Phase Of 1st Stage Of Labor ............................................................................... 47
Second Stage Of Labor. ................................................................................................. 50
Precipitate Labor ........................................................................................................... 51

PREMATURE RUPTURE OF MEMBRANES (PROM) .............................................. 53

Management .................................................................................................................. 53
PROM In Specificx Condition ....................................................................................... 57

The Management Of Pre Term Labor ............................................................................ 58

Management Of Multiple Gestations ............................................................................. 63

6
Diagnosis ...................................................................................................................... 63
Management .................................................................................................................. 63
Ante Partum .................................................................................................................. 63
Route Of Delivery ......................................................................................................... 64
Routine Cesarean Delivery ............................................................................................ 65
Intrapartum.................................................................................................................... 65
Placenta Examination And Zygosity Determination ....................................................... 66
Complication ................................................................................................................. 66

The Management Of Postterm Pregnancy. ..................................................................... 69

Diagnosis Of Post Term Pregnancy ............................................................................... 69
Management Of Post Term Pregnancy........................................................................... 69

Management Of Breech Presentation ............................................................................. 71

Diagonsis ...................................................................................................................... 72
Antenatal Management .................................................................................................. 73
Mode Of Delivery ......................................................................................................... 74

The Management Of Ante Partum Hemorrhage (APH) .................................................. 80

Management Of Hypertensive Disorders Of Pregnancy ................................................. 85

Classification................................................................................................................. 85
Pre-Eclampsia ............................................................................................................... 85
Diagnostic Criteria ........................................................................................................ 85
Signs Of Severity Of Pre-Eclampsia .............................................................................. 86
Investigations ................................................................................................................ 87
Management .................................................................................................................. 87
Eclampsia ...................................................................................................................... 92
General Measures .......................................................................................................... 92
Specific Management .................................................................................................... 92
Chronic Hypertension:................................................................................................... 94

MANAGEMENT OF PREGNANCY ............................................................................ 95

COMPLICATED BY DIABETS ................................................................................... 95

Classification................................................................................................................. 95
Diagnosis ...................................................................................................................... 95
Gestational Diabetes Mellitus ........................................................................................ 95
Overt Diabetes During Pregnancy ................................................................................. 95
Gestational Diabetes (GDM) ......................................................................................... 95
Screening Protocol For Gdm ......................................................................................... 96
Treatment Of GDM ....................................................................................................... 96
Treatment Of Diabetes In Pregnancy ............................................................................. 97
Obstetrics Management Of Diabetes In Pregnancy ........................................................ 99
First Trimester ............................................................................................................... 99

7
Second Trimester .......................................................................................................... 99
Third Trimester ............................................................................................................. 99
Timing And Route Of Delivery ................................................................................... 100

Intrapartum Glycemic Management ............................................................................. 100

Postpartum Management: ............................................................................................ 101

Recommendations On Contraceptions ......................................................................... 102

Management Protocol For Post Partum Haemorrhage .................................................. 104

Causes Of PPH ............................................................................................................ 104

Diagnosis ................................................................................................................... 106

Preventive Measures For PPH ..................................................................................... 111

VAGINAL BIRTH AFTER PREVIOUS CESAREAN DELIVERY (VBAC) ............. 112

Selection Of Candidates For Vbac/Tol......................................................................... 112
Absolute Contraindications For Vbac/Tol.................................................................... 113
MANAGEMENT ........................................................................................................ 113

MANAGEMENT OF Rh ISOIMMUNISATION ........................................................ 115

Fetomaternal Hemorrhage (FMH): .............................................................................. 115
Management Of Unsensitized Rh-Ve/ Du-Neg. Pregnancy .......................................... 115
Management Of Rh Sensitized Pregnancy ................................................................. 116

Amenorrhoea............................................................................................................... 117
Evaluation ................................................................................................................... 117
Steps For Evaluation ................................................................................................... 118

The Evaluation Of Urinary Incontinence In Female ..................................................... 123

THE MANAGEMENT OF GESTATIONAL .............................................................. 129

TROPHOPLASTIC DISEASES (Gtds) ....................................................................... 129

CLASSIFICATION .................................................................................................... 129
Diagnostic Approach ................................................................................................... 129
Management Of Hydatidiform Mole ............................................................................ 130
Follow-Up ................................................................................................................... 131
Management Of Gtds Other Than HFM....................................................................... 131
Management Of Non-Metastatic Malignant GTD ........................................................ 133
Management Of High-Risk Sites Of Metastatic GTD .................................................. 136

THE MANAGEMENT OF INFERTILE COUPLE ..................................................... 137

Criteria For Investigation............................................................................................. 137

8
Assessment Of The Male Partner ................................................................................. 138
Assessment Of The Female Partner ............................................................................. 140

THE MANAGEMENT OF SEXUAL ASSAULT ....................................................... 145

Clinical Evaluation ...................................................................................................... 145
Management ................................................................................................................ 146
Legal Concerns Of Sexual Assault............................................................................... 147

CHEMOTHERAPY FOR OVARIAN TUMOR .......................................................... 148

Principles Of Combination Chemotherapy................................................................... 148
Indication For Use Of Chemotherapy In The Management Of Ovarian Tumor. ........... 151
Chemotherapy For Epithelial Ovarian Tumor .............................................................. 151
Chemotherapy For Germ Cell Tumor Of Ovary........................................................... 153
Administration Of Chemotherapy ................................................................................ 154
Guidelines For Hydration ............................................................................................ 155
Guideline For Antiemesis Management ....................................................................... 156

Cesarean Section ......................................................................................................... 158

Pre Operative Preparation ............................................................................................ 158
Pre Operative Preparation For Elective Cesarean Section ............................................ 159
Classical Cesarean Section: ......................................................................................... 161
Postoperative Follow-Up: ............................................................................................ 161

MANAGEMENT PROTOCOL ON FORCEPS DELIVERIES ................................... 163

Forceps........................................................................................................................ 163
Indications Of Forceps Operation: ............................................................................... 163
Prerequisites For Forceps Operation ............................................................................ 164
Preliminary Preparations For Forces Operation ........................................................... 164
Special Terminology With Forceps Operations: - ........................................................ 165

Management Protocol On Ventouse Deliveries ............................................................ 166

Steps Of Operation: ..................................................................................................... 167
Complications: - .......................................................................................................... 168

MANAGEMENT PROTOCOL On DESTRUCTIVE OPERATION ........................... 169

Craniotomy: - .............................................................................................................. 169
Decapitation: ............................................................................................................... 171
Evisceration: - .......................................................................................................... 172
Cliedotomy: ................................................................................................................ 172
Post Operative Care Of Mother Following Destructive Operation ................................ 172
Complications Of Destructive Operations:- ................................................................. 173

Inter-Sexuality............................................................................................................. 174
Diagnosis Of Inter-Sex: ............................................................................................... 174

9
HIV-1/AIDS In OBGYN ............................................................................................. 178
Prevention Of Mother To Child Transmission (PMTCT) ............................................. 180
Factors Affecting MTCT Of HIV-1 ............................................................................. 180
Care Of The Pregnant Hiv - Infected Woman .............................................................. 181
HIV Infected Women Receiving Antiretroviral Therapy .............................................. 182

HIV Infected Women In Labour Without Prior Therapy .............................................. 183

Postpartum Care: ......................................................................................................... 184
Preoperative Preparation.............................................................................................. 184
Counseling And Testing Of The Health Worker .......................................................... 187

The Management Of Abnormal Uterine Bleeding (AUB) ............................................ 188

Abnormal Uterine Bleeding: ........................................................................................ 188
Dysfunctional Uterine Bleeding (DUB) ....................................................................... 188
Steps In The Evaluation Of AUB................................................................................. 188
Laboratory Evaluation ................................................................................................. 189
Management Of AUB.................................................................................................. 190

The Management Of Abortion And Post Abortion Care............................................... 193

Definitions OF TERMS ............................................................................................... 194
Clinical Stages Of Abortion......................................................................................... 195
Initial Assessment ....................................................................................................... 196
Management ................................................................................................................ 197
Management Of Complications ................................................................................... 198

POST ABORTION FAMILY PLANNING ................................................................. 200

10
 Antenatal Care
Antenatal Care (ANC) is a primary health care as it is Comprehensive, Coordinated and
continuous. ANC is the care given to a pregnant women with the aim of improving the
maternal and perinatal outcome. Currently there is a general consensus that ANC
programs should have consistency, essential contents based on local situation and good
quality with less frequent visits.

Objectives: -
ANC should be a goal-oriented care, with the aim of meeting both the psychological and
medical needs of pregnant women, within the context of health care delivery system,
culture, and religion in which the women live. Thus it should advocate & maintain
optimal health of the woman during pregnancy, labor and pureperium with the aim of
safe motherhood.

Contents of ANC visit

1. Risk Assessment
2. Health Promotion
3. Care Provision.

1. Risk Assessment: -

First visit

At first visit, regardless of trimester, assessment should include:

Present History: -
Name, age, address, religion, education, gravidity, parity, abortion.
Current pregnancy: planned/unplanned, wanted/unwanted,
supported/unsupported.
Last Normal Menstrual Period (LNMP), regularity of menses, and use of
contraception
Assessment of gestational age
Symptoms & signs of pregnancy (if early gestation)
Quickening, vaginal discharge / bleeding
Any complaints / concerns

11
 Past history
Multiple gestation, Preterm / Post term birth, Congenital anomalies
Still birth/Early neonatal death (ENND) ,Abortions and ectopic pregnancy
History of medical and surgical problems
APH / PPH
Hypertension / Eclampsia, SGA/LGA, IUGR, operative deliveries
History of genital mutilation
Sepsis, STDs, other infections

Social, Family History

Family history of DM, HPN, multiple gestation, Congenital abnormality
Personal and family history
Social status & support
Habits of smoking, alcohol abuse or drug use

General Physical Examination

General appearance, vital signs
Height and weight
Clinical sign of anemia, icterus and edema
Systemic examination
Signs of physical abuse

Obstetric Examination
Inspection: Abdominal distention, Symmetry, Streia, Dilated veins, Fetal
movement, any old scars
Palpation (Leopolds maneuver)
Uterine size, Symphysis Fundal Height (SFH) with tape measure or finger
approximation.
Fetal lie, presentation, attitude and engagement
Auscultation:
Fetal heart rate
Special examinations: Ultrasound for biophysical profile, estimated fetal weight
and well-being.
Pelvic assessment, speculum examination as indicated
Laboratory Investigations
Baseline
Hct, blood group & Rh, Coombs test if Rh negative (indirect)
Urinalysis

12
 VDRL

On Indication
Pregnancy test
Serology for HIV & HBV screening (human immunodeficiency virus and
hepatitis virus)
Maternal Serum Alpha Feto Protein (MSAFP) at 16 wks
Serology for TORCH screening (toxoplasma, rubella, cytomegalo virus,
herpes simplex virus and others)
Oral glucose tolerance test (OGTT)
Amniocentesis (ultrasound guided)
Pap smear
Cervical /vaginal smear
Urine culture & sensitivity
Cervical culture & sensitivity
Complete blood count (CBC)
Stool examination
Ultra sonography, Doppler velocimetry
X-ray
CT scan and MRI. (Their use during pregnancy is guarded and not cost
effective)

Subsequent visit
Assessment should include: -

Revising the history:

Identifying risk factors
Complaints & concerns
Fetal movement
Social support/physical abuse

Physical Examination
General appearance,
Vital signs ,weight gain
Clinical sign of anemia/edema or icterus
Examination for previously detected problems
Systemic Examination.
Signs of physical abuse

13
 Obstetric Examination
Symphysis fundal height measurement
Fetal lie & presentation
Fetal well being assessment

Laboratory:
Hct, Rh Antibody (if note done)
Urinalysis
OGTT, Ultrasonography, etc as indicated

2. Health promotion: - (at each visit)

Ante natal Care gives an opportunity for health care providers to nurture confidence
among expectant mothers, reinforce maternal health messages, educate them on labor
pain, options of delivery, possible intervention, place of delivery and the care they
should expect.

Advice & Counsel:

Balanced diet, avoiding alcohol consumption, drugs and smoking.
Rest, activities and sexuality.
Minor complaints of pregnancy.
Personal hygiene.
Planned place of birth, need for clean and safer delivery.
Transportation.
Care of newborn, breast-feeding and & child spacing.
Importance of some interventions (immunization, malaria prophylaxis etc.)
Danger signs & symptoms of pregnancy, emergency care needs, when & where to
seek for help.
Prevention of intestinal parasites.

3. Care Provision: -

Provide: -
Treatment for identified problems
Immunization for tetanus (tetanus toxoid -TT), HBV and
Prevention of mother to child transmission for HIV (PMTCT)

14
 Supplement iron and folic acid; malaria prophylaxis; treat intestinal parasites as
indicated
Stress on the importance of the next visit
Advise to report immediately if any emergency
In Additions to the above, at each visit, look for and manage risk factors &
complications of pregnancy.

Minimum care that should be provided at each ANC visit

Development of individualized birth plan initiated at 1st visit & reviewed at
subsequent visits
Discuss and advise woman's preference and proper place of birth
Discuss and suggest for support if no social support is identified
Ascertain transport means in case of any emergency

Number and frequency of visits:

The traditional recommendation for ANC visit has been that, a woman has her first
visit preferably following the first missed period then every four-week until the 28
weeks of gestation, every fortnight from the 28 weeks through the 36 weeks of
gestation, weekly then after and more frequently if indicated. Current evidences
indicate that reducing the number of visits need not compromise maternal and fetal
outcome, but client satisfaction has been in favor of the traditional approach.
However reduced number of visits can safely be applied to apparently low risk
pregnancies and in resource limited settings.
World Health Organization (WHO) recommends a minimum of 4 visits for normal
pregnancy while disease status could dictate more frequent visits. Women are also
advised for visiting the health institution anytime if they have complaints or
problems. Couples with certain medical or familial genetic disorders are best seen
before conception for the purpose of counseling or controlling the problem under
question.

Timing of ANC visits and provision of care

1st visit:
Should be before the end of the 4th month (16 week)
To establish diagnosis of pregnancy, estimation of gestational age.
To ascertain risk factors, and asses medical status of the mother.

15
 To provide health promotional services (such as education on nutrition
supplements, danger signs of pregnancy, labor, STI &, breast feeding)
To initiates preventive measures (such as immunizations, iron
supplementation, malaria prophylaxis and control of mother to child
transmission of HIV)
Develop individualized birth plan.

2nd visit:
By the 6th -7th month (24-28 weeks)
Similar actions as in the first visit

3rd visit by the 8th month (32weeks)

To screen for hypertension, multiple gestation, anemia, preterm labor,
diabetes, Rh sensitization.
To ascertain fetal growth & well being
To further develop individualized birth plan.
To further continue provision of medical care and health promotional
services

4th visit by the 9th month (36wks)

To screen for pregnancy related disorders like hypertension, APH,
multiple gestation
To ascertain fetal growth, well being, fetal lie, presentation
To strengthen health promotional service & discuss client concern
Finalize the individualized birth plan.

5th visit: -at 40-42 wks (optional)

To assess fetal lie, presentation and fetal biophysical profile (BPP)
To decide on termination or expectant management
To do pelvic score (Bishop's score)
Finalize individualized birth plan.

16
 Ante partum Fetal Well Being Evaluation

Assessment of the well being of the fetus/fetuses during pregnancy especially after the
fetus is considered viable.

INDICATIONS: All pregnancies require fetal well-being assessment; however the

intensity focuses on complicated and high risk categories with increased risk of peri-natal
death and morbidity like:

Post term pregnancy

Diabetes mellitus
Hypertension, PIH
IUGR
Decreased fetal movement
RH Sensitized pregnancy
Unexplained previous peri-natal death
PROM
Maternal disorders like Cardiac, renal illnesses CLD, and chronic lung
pathology etc.

ANTEPARTUM SURVEILLANCE TECHNIQUES:

Symphysis Fundal Height (SFH) measurement
Mother supine, leg straight, bladder empty
Uterine fundus identified and marked
Keep the tape smoothly in contact with natural curve of abdomen along
linea nigra
Gestational age corresponds with SFH in cm at 18-30 weeks
Discrepancy of 2-3cm consider abnormal
Early Ultrasound Examination at 16-18 weeks
Gestational age assessment
Diagnosis of multiple pregnancies
Diagnosis of congenital malformation (best at 16-20 wks)
Daily Fetal Movement Count
To screen low risk pregnancies for fetal jeopardy during ANC
Count to ten approach
Ask the mother to record time taken to count the perceived ten fetal
movements.

17
 Interpretation
Ten (10) movements in the 1st two hours is reassuring (97%)
There should be minimum ten movements in 12 hours.
More than 12 hours to achieve ten movements is an alarming sign. Advise
the mother to contact her physician for further evaluation
Non-stress test
Can be done at out patient department
Mother can sit or tilt to the left
Fetal heartbeat monitored using Doppler, Ultrasound transducer or toco-
dynamometer.

Interpretation
A. Reactive:
Two acceleration of FHB, 15Beats/min from base line lasting 15 seconds in 20
minutes

B. Non reactive:
Criteria for reactivity are not met, extend test time for 40 minute
If still not reactive do Biophysical profile (BPP)

C. Additional unusual FHB pattern that indicate fetal jeopardy include

. Persistent variable deceleration
. Bradycardia (<90 BPM, drop 40 BPM below base line)

Delivery is indicated if these abnormal patterns are seen

CONTRACTION STRESS TEST (CST)

Conducted in labor/delivery suit by trained staff
Mother put in semi fowler position (30-45o)
Base line FHB recorded by Doppler ultrasound, and uterine contraction
using toco- dynamometer
Maternal blood pressure monitored every 10 minutes
Uterine contraction 3/10/ 40-60 achieved spontaneously, by nipple
stimulation or by oxytocin infusion)

Interpretation of contraction stress test

18
 1. Negative. No late deceleration appearing any where on tracing with
adequate contraction.
2. Positive. Late decelerations that are Consistent / persistent in > 50% of
contractions
3. Suspicious Inconsistent late deceleration
4. Hyper stimulation: frequent uterine contraction or lasting for 90
Seconds or 5 contractions in ten min,
5. Unsatisfactory. Quality of tracing inadequate for interpretation or no
adequate contraction

Contraindications for CST

Premature rupture of membranes,
Cervical incompetence,
Multiple pregnancy,
Classical c/s
Non reactive NST
N.B
If result is suspicious , suggest hyper stimulation or are unsatisfactory repeate
after 24 hrs
Because of high false positive rate of CST, Positive CST should be supported
by Standard BPP.
CST should be avoided if NST is Non Reactive.

STANDARD BPP: A real time ultrasound assessment of fetal biophysical variables

including fetal tone, Gross body movement, Fetal breathing movement and amniotic fluid
volume with or without The NST performed for at least 30 minutes.

19
 Biophysical Profile Scoring After Manning
VARIABLES (2) (0)
Fetal breathing One episode > 30 No episode of breathing
movement sec in 30 min
Gross body Three or more Two or less
movement discrete body movements
movements
Tone One episode of Either slow extension
extension return or partial flexion or no movement
to flexion
Amniotic fluid Largest pocket > < 2cm
volume 2cm
** Non stress test Reactive Non reactive
** If four component are normal, may be omitted with out compounding the
validity of test result
SCORE INTERPRETATION MANAGEMENT
10 . Normal Fetus . Repeat test weekly
. Low risk of hypoxia . Twice weekly in high risk

8 . Normal fetus . Repeat test weekly

. Low risk of hypoxia . Twice weekly in high risk
. Oligohydramnios . Suspect chronic hypoxia and plan delivery

6 Suspect severe chronic . GA> 36wks-Delivery

hypoxia . GA<36wks-repeat test in
4-6 hrs and Do L/S ratio
If Ratio <2.0
. Test < 6 Delivery
. Test > 6 - Repeat 6hrs later
4 Suspect Severe chronic If GA > 36wks- Delivery
hypoxia GA < 36wks - Repeat test
with in 2-4 hrs,
If it is < 4 Delivery
0-2 Chronic hypoxia/ Delivery
Imminent fetal demise

Modified BPP Combination of NST and aminotic fluid index

20
 i) Normal M BPP Reactive NST and AFI > 5 cm.
ii) Abnormal M BPP. Non-reactive NST and/or AFI< 5cm.
Note: Abnormal M BPP should be supported by standard BPP and CST

Initiation Of Ante partum Fetal Well Being Evaluation

Gestational age 32- 34 wks, for most high-risk mother.
Pregnancy with multiple risk factors, evaluation can be started at any gestation.
Inform all mothers to follow fetal movement and report of abnormalities.

Frequency of Testing
i) Non persistent indication
Reassuring result with normal pregnancy
Repeating may not be needed
ii) Persistent indication with stable maternal condition
CST wkly
NST, MBPP standard BPP twice/week.
iii) Persistent indication with deteriorating maternal condition
Frequently regardless of time elapsed since last test

Mode of Delivery
In absence of obstetric induction delivery of fetus with abnormal
test may be attempted with indication of labor and continuous fetal
monitoring.
Recent normal test should not preclude intrapartum continuous
monitoring.
Feto- maternal condition should dictate mode and the route of
delivery.

21
 NON-REASSURING FETAL HEART RATE PATTERN
(NRFHRP).Fetal Distress
The Intra partum management of fetal distress is always a challenge. The difficulty of
interpreting fetal heart rate pattern and confusion regarding the definition of perinatal
asphyxia makes the intra partum management of fetal distress difficult.
Non-reassuring fetal heart rate pattern is defined as repetitive late deceleration, loss
of beat-to-beat variability or baseline bradycardia or tachycardia while fetal distress
implies hypoxia and acidosis.
Signs of fetal distress include:
Abnormal fetal heart rate: using intermittent auscultation or continuous electronic
monitoring
Meconium stained amniotic fluid.
Fetal scalp PH indicating acidosis

FETAL HEART RATE (FHR) MONITORING using INTERMITTENT

auscultation

1. Normal pattern: baseline FHR: 120 to 160 beats per minute (bpm), acceleration
with contraction or fetal movement, early deceleration with descent of fetal head
2. Abnormal FHR:
a. Late Deceleration that persists for at least three contractions.
b. Base line tachycardia: Baseline FHR >160 bpm BIOPHYSICAL
PROFILE (possible other causes are maternal fever, drugs causing rapid
maternal heart rate like tocolytic agents, maternal thyrotoxicosis or
amnionitis). In the absence of rapid maternal heart rate, a rapid FHR
should be considered as non reasuring.
c. Baseline FHR <120bpm.

Management of abnormal FHR pattern:

If there is no contraindication for vaginal examination, exclude cord prolapse or cord
presentation. Vaginal examination is indicated if there is early deceleration or FHR<100
bpm (deceleration that is relieved with cessation of contractions) to ascertain the stage of
labor.

In case of APH, institute the management of APH protocol.

In mild APH, consider vasa previa if the abnormal FHR is associated with rupture
of the membranes.

22
 Discontinue oxytocin.
Start oxygen by facemask or nasal catheter/prong (6-8 L./min).
Change maternal position.
Correct maternal hypotension, dehydration and hypoglycemia.
In case of fetal tachycardia, possible causes of maternal tachycardia (including
chorio-amnionitis) should be treated.
If abnormal FHR persists despite the above corrective measures or if there are
other additional signs (meconium stained liquor, high risk factors such as IUGR):
plan delivery: -
1. If the cervix is fully dilated and the fetal head is not more than 1/5above
the Symphysis pubis or the leading bony edge of the head is at plus one or
below station, consider instrumental delivery.
2. If the cervix is not fully dilated or the fetal head is more than 1/5 above the
Symphysis pubis or the leading bony edge of the head is above 0 stations,
delivery should be effected by Cesarean Section

CARDIOTOCOGRAPHIC (CTG) FETAL HEART RATE MONITORING

A. Classification of fetal heart rate patterns

1. Base line FHR: 120-160 bpm on average between peak and depression. Fluctuation:
- (5-15) bpm on base line often referred to as beat-to-beat variability. It is a strong
indicator for interaction between fetal heart and central nervous system.
2. Transient FHR changes
a. Decelerations transient FHB fall in relation to uterine contraction
1. Early deceleration: - reflex bradycardia due to compression of
fetal head during contraction. It is rarely below 100-bpm/30
sec.
2. Late declaration: - Transient fall of FHB that are noted to begin
well after contraction (lag time of 30 sec).
3. Variable deceleration: - Reflex mediated FHB change due to
cord compression.
b. Mixed pattern of all the above mentioned.
c. Acceleration: - transient increase in FHB (15 bpm /15 sec) associated with
uterine contraction or fetal movement.
3. Sustained FHB change:
a. Beat to beat variability: represents interplay between cardio stimulatory and
cardio inhibitory center
i. Short term variability (3-5 bpm)

23
 ii. Long term variability (6-20 bpm)
b. Tachycardia: - Base line FHB>160 bpm
c. Bradycardia: - Base line-FHB<120 bpm
d. Sinusoidal FHR-pattern: -Base line with 120-160 bpm in the absence of
acceleration & fixed short-term variability oscillation below and above base
line.
4. Base line abnormality: -is defined as fetal tachycardia or bradycardia lasting for
more than 10 min.

B. Interpretation of fetal heart rate patterns

a. Normal base line: FHB 120-160 bpm with mild (<5 bpm) to moderate (6-20
bpm) beat-to-beat variability with or without acceleration and mild variable
deceleration.
b. Fetal distress: - moderate to severe variable declaration with absent
variability; late decelerations with absent variability; bradycardia, 100 bpm

Management of FHR abnormalities

1. General principle of management of NRFHRP
1. Patient at high risk of utero-placental insufficiency should be monitored
continuously. After rupture of the membranes, fetal scalp electrode should be
placed to assess fetal heart rate variability.

NB. Serum HIV status should be known before applying any Intra-uterine
electrode as it may increase MTCT.
2. If external technique is in use and there is base line abnormality or deceleration
internal electrode should be placed to asses true variability.
3. For mixed FHR pattern, patient should be managed according to the most
ominous sign.
4. If there is late deceleration, severe early deceleration, base line tachycardia or loss
of variability, stimulation test should be done. If the fetus doesnt respond with
acceleration or abnormal pattern persists, fetal scalp capillary blood should be
obtained for acid base determination.
5. In the presence of maternal fever, fetal capillary blood determination should not
be relied up on as the only indicator of fetal well-being. Sepsis may compromise
fetus despite normal PH.

24
 NB. Invasive procedures like ARM and internal monitoring are contraindicated in
HIV infection.

2. Management of specific FHR abnormalities:

a. Early deceleration: -If FHB <100 bpm

Check for cord prolapse/cord compression and treat accordingly.

b. Late declaration:

Discontinue oxytocin if on oxytocin

drip
Start 02 (6-8 liter/min)
Change maternal position
Correct hypotension with iv fluid or administer vasopressor
If late deceleration is secondary to hypoxia or ketoacidosis, correct the underlying
condition
If FHR doesnt normalize with these interventions, delivery should be conducted
by the quickest and safest method for both mother and fetus

c. Variable deceleration

Discontinue pitocin drip

Do pelvic examination to rule out cord prolapse
Correct maternal hypotension
Change maternal position
Give oxygen by facemask (6-8 l/min.)
Arrest hyper stimulation by tocolysis
If measures dont correct FHR, prepare for delivery

d. Prolonged deceleration:
FHB <80 Bpm lasting for more than 60 sec
Identify and treat the cause accordingly
Change maternal position
Check for cord prolapse and progress of labor

25
 Institute 02 by facemask (6-8 liter/min)
Hydration
If no response to conservative treatment delivery should be accomplished by
the fastest route. ( Instrumental / Cesarean delivery)

26
 Management of labor and Delivery

Definition of Normal labor

Labor is considered normal if the following conditions are fulfilled
Spontaneous onset of labor
Rhythmic and regular uterine contraction
Vertex presentation
Vaginal delivery without active intervention in reasonable time period
No maternal or fetal complication
Diagnostic criteria

True labor-
True labor is defined as a Regular, Rhythmic and Painful contractions with show or
rupture of the membranes resulting in progressive effacement and dilatation of the cervix.

N.B. Show should be disregarded if there is a rupture of membrane or digital vaginal

examination with in 48 hours prior to show.

Admission Criteria

High-risk mothers should be admitted with the diagnosis of latent or active phase of
labor
Mothers with ruptured membranes should be admitted irrespective of the stage of
labor
Low risk and intact membrane admit in active phase (cervix 3cms)

Admission procedure
Warm and friendly acceptance
Immediate assessment of the general conditions of the mother and fetus
including assessment of whether delivery is imminent or not, and to act
accordingly
Appropriate history, physical examination and laboratory investigations as
indicated.
Lab. tests: - blood group and Rh, Hct, U/A, VDRL (if no previous
documentation or no ANC)
For those with ANC record, update Hct and U/A

27
 Review ANC record and present evaluation and plan a scheme of
management during labor and immediate postpartum.
*All admission information should be transferred to a partograph.
Preparation of the vulva and perineum
Clipping of pubic hair if and when needed
Shower : if mobile and wishes
Clothing : loose hospital gown preferably
N.B. Team approach is important in managing mothers in labor, and all abnormal
information should reach to the most senior personnel in charge of the labor ward
activity.

Management during 1st stage

All observations and findings should be recorded on the partograph.

Maternal well-being monitoring

(a) Vital signs:

Pulse- every hourly
Temp. And BP - every 4 hourly or more frequently if indicated

(b) Maternal position

Avoid supine position,
Can assume any position comfortable to her (LLP, RLP, sitting unless
contraindicated.)
Should not be confined to bed unless contraindicated (e.g. sedated patient,
for frequent monitoring, high head and ruptured membranes)
(c) Nutrition
In general avoid oral intake of solid food
Consider fluid diet as a source of water and energy for those mothers
staying longer before delivery (e.g. small sips of sweetened tea or water)
Give clear non-particulate antacid preparation before anesthesia (major
regional or general). 30 mL of sodium citrate 45 minutes before surgery
(if this has passed, repeat 2nd dose)
H2 blocker - IV at least 60 minutes before induction of anesthesia i.e. 200
mg cimetidine IV.

(d) Pain management:

28
 Provide continuous emotional support
Inform laboring mothers about the procedures to which they will
be subjected during labor and delivery
The selected analgesia should be simple to administer, safe to the
mother and fetus, no undue effect on progress of labor, and
available in the unit.
Timing, route, dosage and frequency of administration should be
based on the anticipated interval of time between the drug
administration and delivery.
Avoid combination of antagonist opioids
A small dose given more frequently is preferable to a large one
administered less often
Whenever one uses opioids during labor, one should be prepared
to treat neonatal respiratory depression which includes ventilation,
oxygenation, gentle stimulation and judicious use of the opioid
antagonist, naloxone.
Opioids alone or in combination with phenothiazines
Pethidine injection: 50 mg IM initially. Assess after hr and if not
adequate and side effects not troublesome, repeat 50 mg . Onset of
action with in 10 -20 min and lasts for 2-4 hours
Pethidine injection: 25 mg IV, onset immediately and effect lasts
for 1.5-2 hrs.
Combination of pethidine 50mg IM and phenothiaziazine 25 mgIM
Q 3 to 4 hours
Other new synthetic opioids and phenothiazines
Opioids - butorphanol 1-2mg hourly as needed
Nalbuphine 15- 20 mg iv
Fentanyl 50- 100 mgIm hourly as needed
Phenothiazines - Chloropromazine
Lumbar Epidural Analgesia
Lumbar epidural analgesia provide the best relief of labor pain

Fetal Well - Being Monitoring

a) Fetal heart beat

29
 Count FHR - using Pinnard stethoscope / Doppler
Auscultate immediately after a contraction for 1 min
Q 30 min for low risk and Q 15 min for high risk
Continuous electronic FHR monitoring for high risk (external/internal)
(b) Asses status of liquor for meconium
Grades of meconium
Grade I - good volume of liquor, lightly meconium stained
Grade II - Reasonable volume with a heavy suspension of meconium
Grade III - Thick meconium, which is undiluted and resembles sieved spinach

(c) Fetal acid base determination if available.

MONITORING OF LABOR

Uterine contraction: -
Monitor the frequency /10 minutes, duration and intensity of each

contraction By palpation and or tocodynamometer

3-5 contractions in 10 minutes each lasting 45-60 sec is normal

Monitored every 1 hr. for latent phase and every 30 min. for active phase

1. Descent of fetal head: should be done by abdominal palpation before vaginal

examination

2. Vaginal examination: perform every 2-4 hours to note

Rate of cervical dilatation (at least 1 cm./hr).
Station, position, degree of moulding
After spontaneous rupture of membranes
When there is abnormal FHR pattern
Before giving analgesia
Symptoms suggesting 2nd stage (to confirm the diagnosis)
3. Amniotomy: can be done during one of the vaginal examinations.
( Delay amniotomy in cases of severe LGTI and RVI)
Amniotomy should be done:
- Under aseptic technique
- In a mother in well-established labor,
- Head fixed in the pelvis or cervix well applied to the
presenting part, avoid dislodging,

30
 - Rule out cord presentation before ARM
- Preferably done during contraction or by applying fundal
or suprapubic pressure
- Monitor FHR before and after the procedure

Management during 2nd stage

Second stage is the time from full dilation of the cervix to delivery of the (last) fetus /
fetuses. The median duration of 2 nd stage is 50 min for nullipara and 20 min for
multipara

Diagnosis of prolonged 2nd stage

Nullipara - 2 hr without or 3hr with epidural anesthesia

Multipara- 1 hr without or 2hr with epidural anesthesia

Maternal care and well-being evaluation

Vital signs: continued as 1st stage but more frequently
Bp and PR Q 30 min (if indicated more frequently)
Temp., RR Q 1hr
Evaluate general condition fatigue, pain, physical depletion and state of
hydration
Evaluate the presence of the urge to push and / or effort
Avoid early push; it should start spontaneously.
Keep the mother in LLP till head is visible
Bladder should be emptied before delivery

FHR Monitoring
Q 15 min for low-risk fetus
Q 5 min for high-risk fetus or continuous electronic monitoring

Labor progress evaluation

Evaluate the degree of descent Q 1 hr.
Expect at least 1 cm/hr in nullipara; 2cm/hr decent in multipara

Management of Prolonged 2nd stage

Reevaluate maternal and fetal condition

31
 Rule out inefficient uterine contraction and maternal expulsive effort,
malposition, malpresentation and CPD
Act accordingly

Preparation for delivery

General
Notify the team that delivery is imminent.
Move the woman to the delivery room if it is separate.
Make sure all the equipment for delivery and newborn care are available at the
delivery room.
Position the mother to semi sitting (back up and leg down)
Attendant should be dressed and gloved appropriately (gloves, gowns, apron,
masks, caps, eye protection)
Sterile draping in such a way that only the immediate area about the vulva is
exposed.
Perineal care:- cleaning of the vulva and perineum with antiseptic (downward and
away from the introitus). If pieces of faeces get expelled, wipe them downward.

Assistance of spontaneous delivery

Goal: - Reduction of maternal trauma

Prevention of fetal injury
Initial support to the newborn

(a) Episiotomy: If indicated

Indications
Threat for a perineal tear
Perineal resistance for fetal head descent
Fetal / maternal distress to expedite delivery
Timing performed when fetal head has distended the vulva 2-3 cms
unless early delivery is indicated.
Types -median or mediolateral
Analgesia/anesthesia:
- Continuation of 1st stage analgesia
- N2 O inhalation
- Pudenal block
- Perineal infiltration

32
 (b) Delivery of the Head

Prevent rapid delivery and assist extension of the head.

Assist using modified Ritgens maneuver if extension does not occur with
ease i.e., hand protected with sterile towel placed on the perineum and the
fetal chin palpated and pressed up ward gently effecting extension.
After delivery of the head, wipe the face; aspirate mucus from fetal mouth,
oropharynx first and then nares (use suction catheter in the presence of
thick meconium).
Check for cord around the neck
Disentangle the cord from around the neck and slip it over the head or
clamp at two sites and cut in between if not reducible.
(c) Complete delivery of the rest of the body:
after securing complete delivery,
Wipe the newborns body dry with sterile towels.
Cord clamping: 4-5 cm from fetal umbilicus
Put fetus at the level of the introitus for 3 min before clamping (unless
preterm, small or with Rh isoimmunization)
Take cord blood if indicated.

Immediate newborn care

Prevent heat loss: -

Use warm towel
Change moist/wet towel
Care for the newborn on a table in a thermo-neutral room
Evaluate using APGAR score
Neonatal resuscitation using the Melbourne Chart
Tie the cord and label the baby
Take weight, head circumference and length
Give neonatal eye prophylaxis: - 1% TTC eye ointment
- 0.5% erythromycin
- Vitamin K 1mg IM.
- Immunization
- Handover the newborn to the mother

33
Management of 3rd and 4th stage

I) Definition
3rd stage: - interval between deliveries of the last fetus to delivery of the
complete placenta with attached umbilical cord & fetal membranes.Occurs
with in 15 minutes in approximately 95% of all deliveries.

4th stage: - the 1st hour following completion of the 3rd stage.

ii) Goal of Management: -

The goal of Management of third stage of labor is to prevent maternal mortality

and morbidity from post partum hemorrhage and retained placenta. PPH is
diagnosed when a blood loss of 500ml is observed in the first 24hours following
vaginal birth.

N.B. This amount of bleeding can be catastrophic in mothers with hypertension,

anemia, and small size.

Retained placenta is diagnosed when the placenta fails to separate and get
expelled by the end of 30min after delivery of the baby.

Active Management of 3rd stage:

All women in third stage of labor should be actively managed irrespective of risk
status for post partum hemorrhage

Principle: Use of oxytocic agents immediately after the delivery of the anterior
shoulder of the last fetus followed by CCT.
Oxytocic agents: - Oxytocin 5IU IV Or Oxytocin dilute infusion IV. Or
Syntometrine IM. Or
Ergometrine IV.
N.B: - There is a risk of entrapment of undiagnosed 2nd twin.
There is also a risk of difficulty managing abnormally adherent placenta.
v) Management of Retained Placenta
- If there is no sign of haemorrhage, expectant
management can be extended for additional 30 min
because half of the cases deliver the placenta
spontaneously with in this time. Use oxytocin to

34
 effect uterine contraction.
- Indications for manual removal of the placenta
- At any time during third stage when there is brisk
bleeding and placenta cannot be removed with CCT.
- Retained placenta after expectant management i.e. after
1hr.
Precautions for Manual Removal - aseptic technique and adequate
analgesia/anesthesia.
vi) Uterine Manual Exploration: after delivery of the placenta is
Indicated
- When there is suspicion of a retained placenta part,
- When there is excessive uterine bleeding,
- In case of destructive deliveries, and
- After VBAC when indicated.
vii) Fourth stage management
- Vital signs: BP, PR Q 15min.
- Examine uterine fundus: palpate it to ensure that (1) no
blood gets accumulated in the cavity (2) it is well
contracted. If found relaxed, massage and give oxytocin
if no response.
- Look for vaginal bleeding.
- Inspect the perineum for hematoma.
- Bladder care:
- Encourage urination, and
- If there is retention, catheterize .
- Pain management for episiotomy pain
- Ice bag, cold water or sitz bath.
- NSAIDs (e.g. Ibuprofen) for after pain.

35
Postnatal Care and Observation before Discharge

Observation before Discharge: Minimum duration of observation for an uncomplicated

vaginal delivery is 6 hrs including the 4th stage.

a. Maternal Care
- Observation of her general health
- Physical and emotional well being
and reaction to the newborn
- Encourage: breast-feeding, ambulation, micturition, and facillitate few hour of
undisturbed sleep
- Provide education and support about: -
Infant care, breast-feeding, FP, immunization, physical/
sexual activity, perineal care, what to expect in the
normal puerperium and identification of sign of danger
in the infant/herself, and importance of postnatal
examination.
b. Normal Newborn care
Observation Establishment of feeding
- Normal pattern of toilet
- Surveillance of neonatal problems: temperature,
stability, change of activity, refusal for feeding,
pallor/cyanosis/ jaundice, neonatal reflex tachypnea/
respiratory distress, and vomiting.

2. Criteria for discharge

Mother: - Complete duration of observation with no complication. If any
complication transfer to the respective unit.
Infant: - Does not require further observation (if required, transfer the new born
to neonatal care unit)
Vital signs: axillary temperature (36.10 c 37.20 c)
HR= 110-150bpm
RR= 40-60/min.
Gross P/E
No dysmorphic features or congenital abnormalities( (CNS, GI, Resp, renal,
imperforate anus, ambiguous gentalia, extremities)

36
 No pallor, cyanosis, or jaundice
Well secured umbilical cord stump
Intact neonatal reflexes
Complete lab. investigations if indicated
Vit. K, eye prophylaxis, and immunization should be given.

Finally discharge them with: -

Complete discharge summary note
Prescription of medication if any,
Certificate, and
Postnatal appointments:
1st visit-after a week, and
2nd visit after 6 weeks

37
 INDUCTION AND AUGMENTATION OF LABOR

An induction of labor is the process by which medical or surgical means are used to
initiate and maintain labor any time after the 28th week of gestation. Induction is done
when the benefits of delivery to the fetus or the mother exceed the benefits of continuing
the pregnancy. It could be either as:
Planned (elective)
Emergency
An active labor refers to the occurrence of regular contractions, cervical dilatation 3 cm
or more and cervical length 1 cm or less.
An adequate contraction consists of 3-5 strong contractions in 10 min. each lasting for
45-60 sec.

INDICATIONS

The following are some of the indications for induction of labor. However when to
induce with a given indication is determined by the protocol prepared for each indication
per se.

A. Obstetrical
1. Hypertensive Disorders of Pregnancy including eclampsia
2. Post term pregnancy
3. Intra-uterine Fetal death (IUFD)
4. Congenitally abnormal fetus incompatible with life
5. Premature Rupture of Membranes (PROM)
6. Rh-Isoimmunization
7. Gestational Diabetus mellitus at term
8. Intra-uterine Growth Retardation (IUGR)
9. Placental Abruption and minor degree anterior placenta praevia
10. Chorioamnionitis

B. Maternal Medical Disorders aggravated by Pregnancy

1. Chronic renal disease
2. Chronic hypertension
3. Severe cardiac disease
4. Diabetes mellitus

38
CONTRAINDICATIONS

In general any condition that is contraindication for spontaneous labor and vaginal
delivery should be a contraindication for induction of labor. Contraindications may
include but are not limited to the following;
ABSOLUTE
1. Gross cephalo-pelvic disproportion (CPD)
2. Transverse and oblique lie
3. Footling breech
4. Upper segment Uterine scar
5. Active or culture proven genital herpes (with intact membranes or rupture of
membranes of less than 6 hrs duration)
6. Extensive genital wart
7. Invasive cervical Ca.
8. Pelvic tumor obstructing the birth canal
9. Placenta praevia (major degree)
10. Acute fetal distress
11. Two or more previous lower uterine segment cesarean scar

RELATIVE
1. Grande multi-parity
2. Bad obstetric history
3. Twin pregnancy
4. Pre-maturity
5. Macrosomia
6. One previous lower segment c/s

RISKS AND COMPLICATIONS OF INDUCTION

A. MATERNAL
1. Failed induction
2. Unforeseen CPD leading to obstructed labor
3. Uterine hyper stimulation/tetanic contractions
4. Sepsis
5. Placental abruption
6. Water intoxication
7. Amniotic fluid embolism
8. PPH

39
 9. Uterine rupture

B. FETAL
1. Iatrogenic prematurity
2. Fetal asphyxia
3. Cord prolapse
4. Fetal hemorrhage from vasa previa
5. Fetal pneumonia
6. Neonatal jaundice

VI. Preconditions for induction

Document the indication.

Make sure that there are no contraindications.
Do pelvic scoring (Bishop) and if unfavorable, consider cervical ripening.

Ascertain availability of labor ward staff and also the capacity to do emergency
cesarean section.
Get informed consent from the patient.

BISHOPS PELVIC SCORING SYSTEM

Table 1. Bishops pelvic scoring system

Score Dilatation Effacement Station* Consistency Position
0 Closed 0-30% -3 Firm Posterior
1 1-2cm 40-50% -2 Medium Mid position
2 3-4cm 60-70% -1to +1 Soft Anterior
3 5cm 80% +2 - -

Score 4: unfavorable
Score 5-8: intermediate
Score 9: favorable
*Station reflects a -3 to +3 scale.

Methods of induction

Pharmacological:

40
 1. prostaglandins

PGE2:

3 mg vaginal tab; 1 tab to be inserted in the posterior fornix of the vagina, 12 hrs
before induction is started, every 6 hours, till the cervix becomes favorable
(maximum of four doses).

2.5 mg intravaginal gel; to be applied on the upper vaginal canal mucus membrane
12 hrs before induction is started, every 6 hourly, till the cervix becomes favorable
(maximum of four doses).

0.5 mg intracervical gel; to be applied in the cervical canal 12 hrs before induction is
started, every 6 hourly, till the cervix becomes favorable (maximum of three doses).

Patient is expected to remain recumbent for at least 30 min.

An observation period ranging from 30 min. to 2 hrs. is required
Effects of prostaglandin E2 maybe exaggerated with oxytocin, so induction
with oxytocin should be delayed for 6 hrs.
Doses should only be repeated if Bishop score change is no more than 3.
In case of hyper stimulation, intravenous/subcutaneous terbutaline, 250 g
or magnesium sulfate (2-6 g in 10-20% dilution) maybe used for uterine
relaxation.

2. Ballooned catheters:
16 or 18 gauge Foley catheter.
Assess the baseline Bishop Score the evening prior to induction.
After thoroughly cleaning the vagina and the cervix, a size 16 or 18 Foley
catheter is introduced through the cervix above the internal os using aseptic
technique either digitally or with the aid of a speculum. The balloon is then
inflated with 30-50 ml of sterile saline and pulled gently to the level of the
internal os, where it is left for 12 hrs or until spontaneous expulsion occurs. Apply
light traction on the catheter
In the condom catheter method, the catheter is covered with two condoms (extra
precaution to avoid rupture) from the proximal end to about 8-10 cm towards the
distal end. After inserting the condom-catheter into the cervix, it is filled with
0.9% N/S (800-1000 ml) and the distal part of the catheter is tied with a bandage
connected to a 1-2 kg weight hanging at the edge of the bed.

41
Induction Procedure Using Oxytocin

1. All inductions, except emergency inductions, should be started at 8 a.m.

2. Check indication and Bishop score.
3. Explain the procedure to the patient.
4. Light sedation the previous night of induction.
5. Encourage the mother to empty her rectum on the day of induction.
6. Light fluid diet or NPO in the morning.
7. Monitor maternal Vital signs, uterine activity and FHB according to the protocol for
the management of labor.
8. Check recent hematocrit, Urine analysis and other basic investigations; if not available
order a new one.
9. Place a No.18 venous cannula.
Start oxytocin drip and label the bottle.
Document the time of RM, color and amount of amniotic fluid, and also if there
is any bleeding
10. Oxytocin infusion dosage
Aim to maintain the lowest possible dosage consistent with regular uterine
contraction
Use 0.9% N/S or R/L solution for infusion.
Increase the drop rate every 20 min. until 3-5 contractions are achieved in 10
min. each lasting 40-60 sec.
Dosage is the same for primi-and multi gravidae.

Add 2 IU of oxytocin to 1000 ml of 0.9% N/S

Start at 2 Mu /min., increasing q 20 min. by 2 Mu /min up to 8 Mu /min; then
increase by 4 Mu /min up to a maximum of 32 Mu /min.

42
 Drops / min. Oxytocin mu/min.
20 2
40 4
60 6
80 8

If no adequate contraction, add 2 iu in the same bag and, start with,

50 10
60 12
80 16
If no adequate contraction, add 2 iu in the same bag and, start with,

50 20
60 24
80 32

After initiation of oxytocin infusion,

Follow maternal v/s and input/output
Follow progress of labor
Donot increase the dose of oxytocin once adequate contractions are achieved
If patient in not in established labor after 6 hrs of oxytocin administration, consult the
senior in charge
*A failed induction is diagnosed when there has been no cervical change or descent of
the presenting part after 6-8 hours of labor, or contractions of 3 in 10 min. or 1 every 3
min. has not been achieved.

Start antibiotic treatment if membranes are ruptured for more than 8 hrs
After the labor has entered the active phase, plan to deliver within 8-12 hrs
Continue the oxytocin infusion for 1 hr post partum
If the patient develops tetanic type of uterine contraction, stop the oxytocin drip. And
adjust the dose

43
AUGMENTATION OF LABOR

Definition: Correction of dystocia due to inefficient uterine contractions (power) by the

use of oxytocin.

INDICATION
Poor progress of labor due to inefficient uterine contractions.

CONTRAINDICATIONS
1. Breech presentation
2. CPD
3. Malpositions
4. Invasive cervical ca.
5. Active genital herpes infection
6. Outlet and mid-pelvis contracture
7. Non-reassuring FHB pattern
8. Fetal macrosomia

CONDITIONS TO BE FULFILLED
Proper evaluation of the patient and the fetus (to rule out contraindications)
Maternal rehydration, positioning
The capacity to do emergency c/s
Get an informed consent

PROCEDURE;

Do ARM aseptically if membrane is intact and no contraindications for ARM exists

Start oxytocin infusion
Add 1 IU of oxytocin to 1000 ml of R/L and label the bottle.
Start with 0.5 mu/min. for multipara and 1 mu/min. for primigravida.

44
 The rate of increment should be 1 mu/min. q 20 min. up to maximum dose of 20
mu/min.

Drops/min. Oxytocin mU/min.

20 1
40 2
60 3
80 4

If no adequate contraction, add 1 iu of oxytocin to the same bag and start with,
60 6
80 8

If no adequate contraction, add 1 iu of oxytocin to the same bag and start with,
60 12
80 16

If no good progress, add 1 IU of oxytocin to the same bag and start with,
50 20

During augmentation, monitor;

1. Progress of labor, FHB pattern, maternal status every 10 min.
2. No need to increase the dose after adequate contraction has been reached.
3. Give antibiotics when membrane has ruptured for more than 8 hrs.

45
 MANAGEMENT OF LABOUR ABNORMALITIES

Introduction
Abnormality in progress of labor is a consequence of four distinct abnormalities, which
may exist singly or in combination.

1. Abnormalities of expulsive force ( POWER)

2. Abnormalities of presentation, position or development of the fetus (
PASSENGER)
3. Abnormalities of bony pelvis ( PASSAGE)
4. Abnormalities of birth canal other than bony pelvis.( PASSAGE)

It is prudent to understand what normal labor is to know departure from the normal.
Labor is conventionally divided into three stages: first stage, second stage and third stage.
The first stage has two major phases: latent and active phase of first stage of labor. The
two major questions to be answered before discussing abnormalities of labor are: -

1. When does labor start?

a. Rely on patients best estimate of clock time when painful contraction
became regular.
b. Begin at time of admission. This definition needs to codify admission
criteria, following which labor management is disciplined.
Painful uterine contractions with one of the following
1. Ruptured membranes
2. Show
3. Complete cervical effacement
2. When does a mother enter active phase of 1st stage of labor?

1. When the cervix dilates at a rate of 1.2 cm/hr. for nullipara and 1.5
cm/hr. for multipara.
2. These rates are not achieved at specific cervical dilatation, but
usually achieved at 3-4 cm of cervical dilatation. But 30% of mothers
reach 5 cm. of cervical dilatation without achieving these rates.

46
Labor abnormalities

Latent phase of first stage of labor.

Prolonged latent phase

Definition
When latent phase of 1st stage of labor lasts longer than 20hrs. in nulliparas and
greater than 14hrs. in parous women. (Definition a of onset of labor)
When latent phase lasts longer than 12hrs for nulliparas and 6hrs for parous
women. (Definition b of onset of labor)

Contributing factors
False labor
Myometrial dysfunction
Prematurely administered sedation and conduction analgesia
Poor cervical condition
Significance
Increased risk of subsequent labor abnormalities
Increased cesarean delivery rate
Low APGAR score and increased need of neonatal resuscitation
Increased febrile morbidity & intra partum blood loss.
Treatment options
Adequate rest with therapeutic sedation or narcosis
Pethidine 50mg initially and repeat the same dose if
inadequate.
Morphine sulfate 15-20mg with 10-15mg more if 1st dose has
not made patient somnolent
Oxytocin stimulation as per protocol for augmentation if indicated.

Active phase of 1st stage of labor

25% of nulliparas and 15% of multiparous women develop active phase
abnormalities. This makes it the commonest labor abnormality.

47
 Active phase abnormalities

Protraction disorders

Slow rate of cervical dilatation and descent

a. Protracted active phase dilatation defined as less than 1.2 cm/hr and 1.5
cm/hr of cervical dilatation for nulliparas and multi paras respectively.
b. Protracted descent- defined as < 1cm/hr of descent of fetal head for
nulliparas and < 2cm/hr. for multi paras.
The time interval necessary to diagnose protracted cervical dilatation is when the cervical
dilatation is less than 1cm/hr. or for a minimum of 4hrs.

Arrest disorders
`
Pure forms of arrest disorders have normal progress of labor prior to the arrest but arrest
disorders can complicate a protraction disorder.

a. Arrest of cervical dilatation- No change in cervical

dilatation for >2hrs period for both nulliparas and multi
paras
b. Arrest of descent No demonstrable descent of the head for
more than 1 hour for both nulliparas and multi parous

Management
Before making a diagnosis of active phase abnormalities make sure that the
women is in active phase.
Evaluate for fetopelvic disproportion. 30% of protraction and 50% of arrest
disorders are associated with CPD.
Contracted pelvis is unlikely when
- Diagonal conjugate is normal
- Pelvic side walls are nearly parallel
- Ischial spines are not prominent
- The sacrum is not flat
- The sub-pubic angle is obtuse
- Muller-Hillis maneuver results a 1 cm descent of the head.
In presence of cephalopelvic disproportion perform cesarean delivery

48
In nulliparas women with both protraction and arrest disorder, oxytocin augmentation
is possible despite presence of unfulfilled criteria for exclusion of contracted pelvis.
Reevaluate for malposition and mal presentations.
- Management depends on the type of mal position & mal presentation.
- Cesarean section is done for Brow, Face mento postetrior position and
Persistent occipito-posterior position
Evaluate uterine function
Uterine dysfunction is often protective against some degree of pelvic
contracture or abnormality of fetal size and presentation.

After exclusion of these conditions:

1. If hypotonic dysfunction ( < 180 Montevideo unit in 10 minutes)
Amniotomy performed if the head is fixed and membrane is intact. If
available put intrauterine catheter and fetal scalp electrode for internal
monitoring.
Observe for 30-60 minute, if amniotomy could improve uterine
function.
If no improvement after amniotomy: initiate oxytocin augmentation as
per protocol for augmentation of labor.
2. Uncoordinated uterine action: - Difficult to diagnose in the absence of internal
monitoring. The condition is with an elevated basal tone and/or distorted
pressure gradient with loss of fundal dominance.
Responds favorably for oxytocin augmentation in the absence of CPD,
malposition & malpresentation.

Cesarean Delivery for dystocia

In absence of other emergent indications for expedite delivery of the fetus, cesarean
delivery for dystocia needs a minimum criteria.
Uterine activity of > 200-250 Montevideo unit in 10 minutes (3-5
contractions in 10 minutes each lasting for 45-60 seconds) should be
achieved with or with out oxytocin augmentation
This intensity of uterine action should last for 2-4hrs and fail to effect
cervical dilatation of 1cm/hr.

49
Second stage of labor.
Abnormalities of descent and rotation

The median duration of 2nd stage of labor is:

50 minutes in nullipara and 20 minutes in multipara.

Definition of prolonged 2nd stage is

2hrs in nulliparas & extended to 3 hrs when epidural anesthesia used;
1hr for multiparas and extended to 2 hrs when epidural anesthesia is used.

Management
In the absence of fetal heart rate abnormality, if mother is well hydrated &
reasonably comfortable and if there is some progress of descent or rotation
regardless of how slow, await spontaneous delivery.
Cesarean delivery: if evidence of cephalopelvic disproportion in the second stage
with live fetus.
Oxytocin augmentation: if failure of descent and rotation is due to inadequate
uterine action.
Instrumental delivery: if indications and criterias are fulfilled ( see protocol on
operative deliveries)
Prolongation secondary to malpositions is managed according to the malpositions
diagnosed.
Prolongation secondary to inadequate maternal voluntary effort is managed with
Appropriate encouragement & instruction
Careful selection and timing of anesthesia not to interfere with voluntary
force.
Allow epidural block to wear off its paralytic effect and can push to level
appropriate for out let forceps & out let vacuum delivery. Intervention is
allowed for this indication when the preconditions are met.
For women who cannot bear due to pain which over ride the urge of
bearing down analgesics like -N2O can be used (safe for both fetus &
mother.)

50
Malpositions of the Occiput
Occiput posterior

Most undergo spontaneous rotation to occiput anterior position and progress of

labor and delivery does not necessarily differ but 10% of these persist in occiput
posterior position.

Management of persistent occiput posterior position

Augment labor if there is hypotonic uterine action,
Await spontaneous delivery- even if first stage and second stage of labor are
slightly prolonged.
Forceps delivery as an occiput posterior position if the preconditions for low and
out let forceps delivery is met.
Force of traction minimized by performing generous
episiotomy.
Forceps applied at occipito-mental diameter.
Vacuum assisted delivery:
Persistent Occiput Transverse Position
In the absence of pelvic architecture abnormality the condition is transient.
Occurs with hypotonic uterine action, which could be either spontaneous or
secondary to regional anesthesia.

Options of management

1. Oxytocin augmentation: Hypotonic uterine action without cephalopelvic

disproportion:
2. Manual rotation to OA or OP position with subsequent forceps delivery .
3. Cesarean delivery: In the presence of contracted pelvis, abnormal pelvic
architecture.
Precipitate Labor

Definition
Expulsion of fetus in < 3 hrs of labor or
Cervical dilatation rate of >5cm/hr. in nulliparas,

51
 10cm/hr for multiparous. The condition complicates 2% of labor, 93% of them are
multiparous and typically have uterine contractions more often than every 2
minutes.

Maternal effect
Increased lacerations of cervix, vagina, vulva or perineum
Increased risk of amniotic fluid embolism
Postpartum hemmorhage because of uterine atony.
Fetal Morbidity and mortality due to abruption & hypoxia
Increased intracranial trauma, Erb-Duchenne palsy
Unattended delivery fetal Trauma,

Treatment
Discontinue oxytocics if in use
Open Ivline with N/S or R/L and prepare for management of possible PPH and
perineal laceration.
Be ready for neonatal resuscitation and repair of genital trauma.
Cervical stenosis (dystocia)
May follow previous conization, large loop excision of the transformation zone,
and amputation of the cervix.
A conglutinated cervix may undergo effacement but cervical Os may not dilate.

Management Options
Finger tip dilatation of the cervical Os usually results in dilatation and subsequent
vaginal delivery
Even if almost all yields during labor, in very difficult situation cesarean delivery
may be mandated.

52
 PREMATURE RUPTURE OF MEMBRANES (PROM)
Premature rupture of the fetal membranes (PROM) is rupture of membranes before the
onset of labor after 28 completed weeks of gestation. It is one of the most common and
controversial problems in Obstetrics. The reported incidence of PROM varies between
3% -19% and is associated with high maternal and perinatal mortality and morbidity.
In 80% of term PROM patients, labor starts with in 24 hrs. On the other hand 70-80% of
preterm PROM patients deliver with in the 1 st week and more than 50% of these deliver
with in the 1st 4 days.

Risk Factors
Lower socioeconomic status lower genital tract infections
RTI)
Intrauterine Infection Vaginal bleeding
Cervical Conization, Excessive uterine distension
Cigarette smoking during pregnancy Emergency cervical cerclage
Physical weakening of the membranes

Definitions of terms
LATENCY PERIOD: is the interval between rupture of membranes and the onset of
labor.
PROLONGED PROM is rupture of membranes for more than 12 hrs.

CHORIOAMNIONITS (CA)
Signs of Chorioamnionitis: -
A maternal temperature of 380 c
Uterine tenderness
Foul smelling Amniotic fluid
Increasing WBC Count
Maternal or fetal tachycardia.
Sub-clinical CA is diagnosed by Amniotic Fluid study .
(See Appendix II C)
Management
General Principles
1. Confirm the diagnosis,
2. Evaluate for presence of intrauterine infection and/or labor
3. Determine the gestational age
4. Evaluate fetal condition.
DIAGNOSIS (flow chart)

53
 History

-Gush or Leakage of fluid per vagina

- Is she in Labor?
No Yes

Speculum /digital examination*

Sterile speculum Examination

Valsalva maneuver

Leakage through cervix

No leakage through cervix
Presence of meconium/vernix

Pooling at post No pooling

fornix

ROM Nitrazin paper test Pad test for 24hrs

Fern test

+ve -ve
No wetting Wetting
-No urineferous smell
-No vaginal discharge
(vagnitis)

Suspicious

Treat as PROM

U/S
Oligohydramnios**

* Dont do digital vaginal examination in patients with PROM who are not in labor
- Decrease the number of digital vaginal examination even in the presence of labor
** Oligohydramnios: - in the absence of severe IUGR and renal agenesis indicates possible ROM

Management:

Admit:

54
 1. To the wards if preterm PROM with no evidence of chorio-amnionitis and not in
labor
2. To the labor ward if term PROM, prom in labor of any gestational age or PROM
with evidences of chorio-amnionitis at any gestation.

Management of Preterm PROM with no evidence of labor or intrauterine infection:

Start prophylactic Antibiotics using:
Ampicillin 2 gm IV QID/48hrs
Erythromycin 500mg IV QID/48hrs
Followed by
Amoxicllin 500mg PO TID/ for 5-7 days
Erythromycin 500mg PO QID/for 5-7 days

Follow closely using PROM chart:

Vital signs every 4-6 hours ( BP, PR, T,RR)
FHR every 6 hours
Abdominal tenderness once /day
Abnormal vaginal discharge once/day
White blood cell count every other day
Fetal biophysical profile twice /week

Follow the pregnancy until term if all indicators are within normal limits or

Terminate pregnancy if evidence of Chorio-amnionitis or fetal jeopardy

Management of Term PROM:

Admit and follow for spontaneous onset of labor within 8 hrs after the rupture of
the membranes
If labor sets in spontaneously follow the progress as in normal labor
If labor fails to set in spontaneously, start induction according to the protocol after
meticulous evaluation

Management of PROM with Chorio-amnionitis:

Admit and start Triple IV antibiotics
Terminate pregnancy by the appropriate way

55
Note: For the Management of Preterm Delivery and Labor see Protocol on Preterm
Labor & Labor

APPENDIX

I. Antibiotic Use in PROM

Advantages
Increased latency period
Decrease the incidence of maternal and neonatal morbidity and mortality
Indications
A. Prophylactic

1.Preterm PROM with expectant management (<34 weeks) in the absence of

labor
- Ampicillin 2 gm IV QID/48hrs
- Erythromycin 500mg IV QID/48hrs
Followed by
Amoxicillin 500mg PO TID/ for 5-7 days
- Erythromycin 500mg PO QID/for 5-7 days
2. Prolonged PROM in labor
- Ampicillin 2gm IV QID till delivery

B. Therapeutic
Clinical Intra Amniotic Infection
i. Ampicillin 2gm IV QID/ for 7-10days
-Gentamycin 80mg IV TID/ for 7-10days
-Clindamycin 900mg IV TID/ for 7-10days
* If Clindamycin is not available
- Chloramphenicol 1gm IV QID or
- Metronidazole 500mg IV TID
ii. Single agent treatment
- Ceftriaxone 1gm IV BID/10days

II. Diagnostic Tests in PROM

A. Nitrazin paper test

56
 PH of the vagina is 4.5-6.0
PH of the amniotic fluid is 7.1 7.3
It changes color from yellow green to dark blue at PH >6.5
False +ve results if:
Blood, Semen contamination
Alkaline antiseptics
Bacterial vaginosis
Tap water
False ve if:- Minimal residual fluid

B. Ferning
Swab the posterior fornix and allow the vaginal fluid to dry on a slide.
Arborization (Ferning) under microscope is a positive result
False +ve if cervical mucus and NaCl solution.

C. Amniocentesis
- Important is demonstration of fetal pulmonary maturity and Intra amniotic infection
- The mother should be in Trendelenburg position prior to the procedure.
- It should be done guided by U/S
- The success rate in preterm PROM is between 50-96%.
In testing Intra amniotic infection, the following results are taken as positive results
i. Culture- Bacterial colony count>10 2/ml fluid.
ii. Gram stain - Presence of bacteria
iii. Glucose level < 15mg/dl.
iv. WBC 100/ml

III. PROM in Specificx Condition

1. Cervical Cerclage and PROM:Remove cerclage and follow as preterm PROM.
2. Viral Infection (Herpes genitalis, HIV) and PROM
- Route of delivery is abdominal if: -
- Duration of membrane rupture< 4 hrs
- There is active herpes genitalis

57
 The Management of pre term labor
Pre term labor (PTL) - is defined as labor occurring after 28 but before 37 completed
weeks of gestation. Depending on the socioeconomic status and a number of other
factors, pre term labor complicates 5-15 % of all pregnancies.
The single most important complication of pre term labor is pre-maturity and the care of
premature infant is costly compared with term infants. Those born prematurely suffer
greatly increased morbidity and mortality (e.g. functional disorders, abnormalities of
growth and development) Thus, every effort should be made to prevent or inhibit pre
term labor. If it cannot be inhibited or is best allowed continuing, it should be conducted
with the least possible trauma to the mother and fetus.

DIAGNOSIS OF preterm Labor

A. Symptoms and Signs

1. Labor pain/ show

2. Uterine contractions >2/10/30
3. Cervical dilatation and effacement;
- Progressive changes in the cervix
- Cervical dilatation of 2cm or more
- Cervical effacement of 80% or more.

B. Trans vaginal ultrasound showing:

- Cervical length < 3cm

LABORATORY STUDIES

1. CBC with differential count

2. Urine analysis, culture and sensitivity
3. Ultra sound for gestational age
4. Amniocentesis for:
- Maturity assessment
- Bacteriological study
5. Electrolytes and blood sugar level for patients requiring tocolysis.

58
 MANAGEMENT
The patient should be observed for 30-60 minutes to confirm the diagnosis and initiate
appropriate management.

Table 1. Management of preterm Labor based on the presence of uterine contractions and
the degree of cervical dilation & effacement.

Uterine Cervical
Group contractions dilatation & Diagnosis Management
effacement
I NO No No labor None
II Yes No or <4cm & Preterm labor Hydration
<80% & Sedation
Yes>cm >80% Incompetent cervix Bed rest
III No consider
cerclage
IV Yes Yes > 3 Pre term labor Tocolysis

1. Two or more contractions every 10 min for 30 sec.

2. Dilatation < 4cm & effacement < 80%
3. Effacement of 80% with dilation of 2 cm or more or change with observation
A. Preterm Labor should be allowed to continue in:
1- Maternal diseases and disorders

Severe hypertensive disease (e.g. acute exacerbation of chronic

hypertension, eclampsia, severe pre-eclampsia)
Pulmonary or cardiac disease (pulmonary edema, ARDS, valvular
heart diseases, tachyarrhythmia)
Maternal hemorrhage (APH, DIC)

2- Fetal diseases and disorders

Fetal Death
Polyhydramnios
Severe IUGR
Fetal distress
Intrauterine infections (chorio-amnionitis)

59
 Erythroblastosis fetalis
3- Miscellaneous
Ruptured membranes
Bulging membranes
Cervical dilatation > 4 cm and effacement of 80 %
Inaccurate dating of GA. (i.e. fetus is mature)

B. Treatment with Sedation and hydration should be initiated:

For group II patients in table 1.

C. Tocoloysis should be considered

For Group IV and failed group II patients
If:
1. The fetus is apparently healthy
2. GA is between 28-34 weeks (up to 37 completed weeks if
intensive neonatal care is not available).
3. Cervical dilatation is < 4cm & effacement < 80%
4. The membranes are intact
Drugs used for tocolysis:
First line agents
-Adrenergic* (Ritodrine, Terbutaline, Fenoterol)
Magnesium sulfate
Second line drugs
Anti-prostaglandins** (Indomethacin, Naproxen)
Calcium channel blockers ***(Nifedipine)
* -Adrenergic are associated with more common and severe side effects than
magnesium sulfate.

** Fetal and neonatal side effects limit the use of anti-prostaglandins as toclolytic agents
*** Experience on the use of calcium channel blockers is very limited.

Protocol for the use of Mg So4

Dosage and administration Magnesium sulfate:
4-6gm loading dose IV over 30min, then 2-4gm/hr.
Oral, 2 gm magnesium gluconate q 4 hrs.
If contractions recur after discontinuation of the infusion the procedure may be
repeated.

60
 Asses the Urine out put , Respiratory rate and deep tendon reflexes while administering MGSO4 since magnesium toxicity

may lead to
Respiratory paralysis at 15 mEq/L and cardiac arrest at 25mEq/L.
With infusion rate > 4gm/hr or if there is renal impairment, serum concentrations
should be measured.
Side effects:
Pulmonary edema
Chest pain
Severe nausea or flushing
Drowsiness or blurred vision
Antidote: CA gluconate 10%-10ml IV
Contraindications: to magnesium sulfate use include myasthenia gravis, myocardial
damage and impaired renal function.

D. Glucocorticoid therapy
Betamethasone 12 mg IM in 2 doses 24 hrs apart
Dexametasone 6mg 8hrly for 2 days

E. Conduct of labor and delivery

a. Fetal monitoring
Continuous FHR monitoring or
Intermittent FHR monitoring every 15 minutes

b. Anesthesia /analgesia
Epidural
Pudendal block
General Anesthesia for C/S
c. Delivery
In vaginal delivery
Wide episiotomy
Prophylactic Forceps

In Cesarean Delivery C/S- delivery

For LBW and non vertex presentations

61
 F. Prevention of pre term labor

Educate women at high risk about signs and symptoms of pre term labor
Follow closely with weekly or biweekly physical examination in those at high risk
Identify and manage risk factors

62
 Management of Multiple Gestations
Twin gestations account for approximately 1% of all deliveries. These gestations,
however, account for approximately 10% of the perinatal mortality.
Diagnosis
Suggestive findings
1. Family history of twins
2. Persistent hyperemesis
3. Very early onset of severe pre-eclampsia
4. Pregnancy following pharmacological induction of ovulation or assisted
reproduction.
5. Big for date uterus
6. Uterine growth is more rapid than normal
7. Unexplainable excessive weight gain
Positive signs

Palpation of more than one head or breeches

Two fetal hearts heard at the same time by two observers and differing in rate by
at least 10 beats per minute
Ultrasonography
o Demonstrates the presence of two or more fetal gestational sacs or fetuses
X-ray of the abdomen ( Rarely done)
o Show more than one fetal skeletons
Not used in less than 18 weeks of gestation

Management
Ante partum
Nutritional
Consumption of energy sources should be increased by 300 kcal/day
above that of singleton pregnancy
Supplementation of Iron and folic acid
Iron 60 to 120 mg/d
Folic acid 1 mg/d
Frequent prenatal visit screen for high risk conditions like PIH, and pretrerm labor
Rest
Limited physical activities
Early work leave
Ultrasound for the evaluation of

63
 Placentation (amnionicity and chorionicity)
Number of fetuses
Fetal Amniotic fluid
Placental abnormalities
The growth of each fetus
The presence of congenital anomaly (ies)

Ante partum surveillance is indicated in complicated multifetal gestation

Techniques:
Modified biophysical profile
Fetal movement counting (Cardiffs count to ten method )
Preterm labor
Tocolytic agents: For short-term prolongation of pregnancy
Corticosteroid administration: before 34 weeks of gestation
PROM
Manage like singleton pregnancies
VBAC
Contraindicated!
Timing of delivery:
All should undergo delivery by 40 weeks of gestation
Fetal lung maturity should be assessed if elective delivery is considered
before 38 weeks of gestation.

Route of delivery

Induction and Augmentation is contraindicated in twins

Twin A-vertex/Twin B-vertex-

Deliver vaginally. C/s should only be performed for the same indications applied to
singleton gestations

Twin A-vertex/Twin B-Non vertex

Twin A-vaginal
Twin B: vaginal: for neonate with an EFW greater than 1500gms options: -
ECV
Assisted breech delivery
Total breech extraction

64
 Internal podalic version and breech extraction
C/s for any other indication

Twin A-Non-vertex c/s delivery

Routine cesarean delivery
Conjoined twins
Placenta praevia
Mono amniotic twins
Possible inter locking twins

Intrapartum
All preparations should be made for resuscitation and special care of babies of
LBW.
I. Labor and delivery
Ascertain fetal number, presentations, EFW and placental location
Blood transfusion products should be readily available
Close monitoring of FHR in all fetuses
Use minimal analgesia for labor
Epidural
Pundendal block
Regional/General Anesthesia for C/S
Following the delivery of 1st twin
Cut the cord as far out side the vagina as possible and clamp
Determine the lie and presentation of the second twin and look for possible occult
cord prolapse or cord entanglement.
If the vertex/breech is in or over the inlet and the uterus is contracting- ARM
should be done on the second sac.
If uterine inertia has set in start on oxytocin drip following amniotomy
When either twin shows signs of persistent compromise and vaginal delivery is
not imminent, proceed promptly to c/s delivery.
Interval between deliveries should not be more than 30 minutes

Third stage of labor should be actively managed.

65
Placenta examination and zygosity determination

Placentas is /are delivered after both twins have been born

Check for chorionicity amnionicity, number of placenta vascular communication
and completeness.
Examine the dividing membrane In order to determine zygosity.

Monozygotic: Commonly have a transparent (thin) septum made up of 2 amniotic

membranes only (no chorion and no decidua)
Dizygotic: Always have an opaque (thick) septum made up of 2 chorions, 2 amnions, and
an intervening decidua
Complication
1.Delayed delivery of the second Twin
2. Discordant Twins

A difference in EFW of greater than 20 % between twin A and Twin B expressed as

percentage of the larger twins weight
Ante partum evaluation
- Serial ultrasound every 4 weeks
- Biophysical profile starting from 28 weeks
Termination of the pregnancy
- When the BPP is poor
3.Twin to Twin Transfusion syndrome (TTTS)
Diagnosis: -
Placental vascular connection
Hgb differences greater than 5 g/dl
Inter twin birth weight difference greater than 20%
Hydramnios in the large twin, oligohydramnios in a growth restricted fetus
Monochorionicity, and same sex
Therapy:
Serial amniocentesis for hydramnios
4.Death of one fetus
Management: - Expectant
Clotting profile every week
Fetal surveillance

66
 No intervention aimed at arresting the labor when the diagnosis is made during
active labor

5.Conjoined Twin
Suspicion provoking factors
Finding of single fetal heart in multiple pregnancy
Lack of engagement when the lie is longitudinal
A similar parallel lie in (vertex-vertex, breech-breech)
An abnormal fetal attitude
Method of diagnosis
U/s
Plane film of the abdomen
Amniography
Mode of delivery
C/s (lower segment vertical incision/Classical)
Destructive operations
- When infant dead and part of the fetus has been born

6.Interlocking of Twins

One may impede the descent and delivery of the other.

Management:
a. Collision, Impaction, Compaction
Avoid strong traction and fundal pressure
Push the second twin out of the pelvis under deep anesthesia
Then deliver the first and second twin in the usual way
If the method fails and babies are alive do c/s

67
b. Chin to chin interlocking

Avoid traction on the first twin

Unlock the chin under anesthesia and the second twin is pushed out of the way
If the first baby dies, break the locking by decapitating the first twin
delivery of the second baby and delivery of the head of the first baby by traction.

6. Triplets or other higher order pregnancies must be considered:

When ever multi-fetal gestation is suspected
In all pregnancies resulting from ovulations induced by gonadotropins or
clomiphene

Diagnosis
Ultrasonography
X-ray during the late 2nd and 3rd trimester

Management
Similar to twin
Mode of delivery
Cesarean section: virtually for all high ordered multiple gestation
Vaginal delivery: for those fetuses who are markedly immature or complications
that make cesarean delivery hazardous to the mother.

68
 THE MANAGEMENT OF POSTTERM PREGNANCY.
Post term pregnancy is pregnancy that advances to 42 (294days) completed weeks of
gestation from the last normal menstrual period (LNMP). It is a common high-risk
problem complicating 3-12% of pregnancies. Post term pregnancy is associated with
maternal morbidity, prenatal morbidity and mortality as a result of high rate of operative
delivery, macrosomia and perinatal asphyxia. Accurate diagnosis and management of
post term pregnancy can reduce the risk of adverse pregnancy outcome.

Diagnosis of Post Term Pregnancy

Establish accurate date:
a) History
Define the LNMP and determine the regularity of menses. The expected date of
delivery (EDD) should be adjusted by number of days that the cycle varied form
the usual 28-days.
The presence of abnormal uterine bleeding and the date on which hormonal
contraceptive method was discontinued should be noted.
Date of quickening (18 weeks in primi and 16weeks in multips)
Date of conception. (e.g. ovulation induction and assisted reproductive treatment)
b). Physical examination
First trimester pelvic examination to determine uterine size
Symphysis fundal height in centimeters compares favorably with gestation age at
approximately 20-34 weeks of gestation.
At 20 wks of gestation, fundal height is at the level of the umbilicus.
Fetal heart tones:
Fetoscope at 18-20 wks
Doppler at 10-12wks
c) Investigations
Positive pregnancy test. (In urine by 6 wks from LNMP.)
Ultrasound.
First trimester (accuracy 1wk): gestation sac, crown rump length
Second trimester (accuracy 10-14days): femur length, biparietal diameter
Third trimester (accuracy 2-3wks): biparietal diameter, femur length

Management of Post Term Pregnancy

Confirm the gestational age

69
 Review the prenatal case document
Do physical examinations to:
Estimate fetal size, ascertain viability
Assess the adequacy of the pelvis, and favorability of cervix (Bishops
score)

Two management options are permissible

1. Direct termination
Induce at:
42 completed weeks in all cases with favorable cervix
42 completed weeks by ripening the cervix if unfavorable.
43 wks of gestation irrespective of cervical status
Cesarean section if contraindication for induction or vaginal delivery
exists.
2. Expectant management:
42-43 completed weeks of gestation with unripe cervix but reliable fetal
condition.
Women with uncertain date and that appear late in pregnancy.
Patients are followed at the outpatient level with appropriate ante
partum fetal well-being test.
Bishops score is reassessed during the follow up.
Termination is done if there is fetal jeopardy or the cervix is ripe or
gestation age advances beyond 43 completed wks of gestation.
a) Check BP, weight, fundal height, fetal heart rate, fetal movement and
Bishops score
b) Kick chart: - < 10 kicks per 12 hrs or < 3 kicks per 1hr (morning, afternoon,
evening), further testing required
c) Biophysical Profile (BPP)
If BPP is < 8, consider induction of labor
d) Non stress test
Twice weekly. If non-reactive, do oxytocin challenges test (OCT/CST).
If reactive terminate pregnancy
e) Oxytocin challenge test weekly. Terminate pregnancy if test is positive
Note that parallel testing for fetal well-being should be preferred than
branched testing to avoid loss of a mature fetus. Therefore a single abnormal
test is satisfactory to consider termination of the pregnancy.

70
Management of Labor and Delivery
As per induction and labor management protocol.
Patients are scheduled for induction from outpatient unless otherwise induction on
emergency ground or admission for other obstetrical risk factors is indicated
1st Stage of labor: Close follow-up of the fetal well being by CTG monitoring or
intermittent auscultation every 15 minutes in relation to contractions

2nd stage : Anticipate

- Shoulder dystocia
- PPH
- Genital (birth canal) trauma.
- Fetal distress
- Meconium aspiration syndrome.

CARE OF THE NEONATE

Oropharyngeal suctioning before the delivery of the chest to prevent meconium
aspiration.
Prevent neonatal hypoglycemia (wt 4000 gm.)
Prevent hypothermia.
3rd Stage: Actively manage the third stage

MANAGEMENT OF BREECH PRESENTATION

Breech presentation is diagnosed when the fetus assumes a longitudinal lie with the
cephalic pole in the uterine fundus and caudal pole at the pelvic brim. It complicates

71
3-4% of deliveries at term and is associated with increased maternal and perinatal
morbidity and mortality.

I. DIAGONSIS
History-
Fetal kick, low in the abdomen
Maternal sub costal discomfort (due to the hard head)
Physical examination
Abdominal palpation reveals
- Round, globular smooth head occupying the fundus, which will be
ballotable in the presence of adequate amniotic fluid .
- Narrow and softer breech occupies the lower pole of the uterus, which
may be mobile above pelvic brim or may dip into it.
- Fetal heartbeat will be heard more easily at or above the umbilicus

Vaginal examination: to ascertain the diagnosis, asses the pelvic capacity and rule
out cord prolapse.
Prior to labor:
- High presenting part with softer consistency and irregular out line, with out hard
vault of the skull, suture lines and fontanelles.

In labor
- Soft irregular mass with anal orifice, ischial tuberosity, genital grove, and external
genitalia is felt.
- The sacrum is the denominator of breech presentation by which the position of
breech is expressed.
- In footling or complete breech foot may be felt.
- If membrane has been ruptured the examining finger may be smeared with
meconium.

Differntial Diagnosis
- Face presentation, which should be differentiated by the presence of the hard
maxilla and suckling in presence of live fetus.
- Compound presentation

Ultrasound to:

72
 Confirm the diagnosis
Screening for fetal malformations
Biophysical profile
Status of flexion of head
Gestational age estimation
Estimation of fetal weight
Localization of the placenta
X-ray to:
Confirm the diagnosis (if Ultrasound is not available)
Rule out multiple gestations
Determine the attitude
Make pelvimetry
CT-Scan: - Is the best method for pelvimetry

Antenatal Management
ANC as other pregnant mothers
External Cephalic Version
Objective: To have Vertex presentation in labour, this is associated with
Minimal risk maternal and perinatal risk .
Indication: Non-cephalic presentation at or after 36 weeks of gestation.
Contra Indications for ECV
Multiple pregnancies
Evidence of utero-placental insufficiency
Significant third trimester bleeding
Suspected IUGR
Amniotic fluid abnormalities
Uterine Malformations
APH
Maternal cardiac disease
Hypertensive disorders of pregnancy
Non reassuring fetal heart rate pattern
Major fetal anomaly
Scarred uterus
Theoretical risks of ECV include:
Placental separation
Cord entanglement and sudden fetal death

73
 Premature rupture of the membranes
Precipitation of preterm labor
Uterine scar dehiscence
Transplacental haemorrhage leading to rhesus sensitisation
Patient Selection
Patient should have completed 36 weeks of gestation
Contra indications must not be there
Decision for elective caesarean section for reasons other than the
breech presentation must not be there.
Technique of ECV
Real time Ultra Sound examination is done to confirm diagnosis and asses
adequacy of amniotic fluid, estimate fetal weight, localize placenta,
ascertain gestation age, & rule out obvious fetal malformation
Should be carried out in a labour & delivery unit
Non-stress test/biophysical profile is done to assess fetal well being.
If available & judged that uterine relaxation is needed Terbutaline sulphate
250mg is given subcutaneous 20 minutes prior to the procedure,
Forward roll of the fetus is 1st attempted if unsuccessful back flip
technique is tried. The presenting part is lifted up before attempting to roll
the fetus.
Check FHR after each attempt
- Version attempts is discontinued, if there is:
Excessive maternal discomfort
Persistent abnormal FHR
After multiple failed attempts
- Administer Anti- D immunoglobulin given to Rh-negative
non-sensitised women
Repeat Non stress test after the version until a normal test is obtained.

Choice of Mode of Delivery

3.1. Absolute indications for caesarean delivery:
Estimated fetal weight greater than 3500
Any degree of pelvic contracture
Footling breech presentation
Breech presentation with hyper extended head

74
 Breech with other obstetric indications for caesarean
Sever intrauterine uterine growth restriction
Breech with poor obstetric performance
History of infertility
Primigravid over the age of 35 years
Previous Rh sensitisation

a. Indications with unsettled benefit from direct caesarean section:

In this group, management should be individualized depending on the set up, the
health service infrastructure available and the obstetric population.
Preterm at gestational age between 28 to 34 weeks in a mother with active labor
or in need of delivery, or estimated fetal weight (EFW) of 1000 -1500g
No labor with maternal or fetal indication for delivery as in PIH or PROM > 12
hrs or post term pregnancy (Induction for vaginal breech delivery Vs direct
caesarean section.)
A request for sterilization
Maternal request for abdominal delivery
In our set up with the limited health service coverage especially in emergency obstetric
care, these group of cases have to be offered a trial of vaginal breech delivery (VBD) to
decrease the rate of caesarean section which has an impact on future obstetric life of the
mother.

3.2. VAGINAL BREECH DELIVERY TRIAL SHOULD BE ALLOWED IN

Cases with no absolute maternal or fetal indication for direct caesarean section
EFW should be <3500gm
Presentation should be frank or complete breech
The head should be flexed
The pelvis should be judged to be adequate
Gross fetal malformation judged to be incompatible with extra uterine life.

* NB. The most experienced medical attendant available should attend the delivery with
anaesthetist and a person capable of neonatal resuscitation should be around.
4. Labour management:

4.1. Admission evaluation should include

Complete obstetric History and physical examination
Whenever possible ultra sound evaluation should be done

75
 Clinical and X-ray pelvimetry, if there is doubt about pelvic adequacy.
Hgb & blood group determined
Inform the mother with relevant information
First stage of labour:
Should be followed as usual, but vaginal examination should be done
and FHB monitored following rupture of membranes to rule out cord
accidents.
Progress of labour in breech presentation is not remarkably different
from vertex presentation.
Augmentation of labour is contraindicated in breech presentation.
The mother should be instructed not to push till full cervical dilatation
is achieved.
Epidural anaesthesia is better avoided as it could prolong 2 nd stage of
labour by precluding maternal bearing down effort.

4.3. Second stage of labor:

Delivery may occur in one of the three ways

A. Spontaneous VBD
The infant is expelled entirely spontaneously without any help (traction or
manipulation) other than support.
This occurs rarely except for premature babies with a multi-parous mother
Carry a significantly higher perinatal mortality and morbidity

B. Assisted vaginal breech delivery (partial breech extraction)

Patient kept in lithotomy position and bladder emptied
Vaginal examination done to ascertain full cervical dilatation, presence
of cord prolapse or entanglement.
Instruct the mother to bear down with every contraction.
Do episiotomy when the fetal anus is visible & perineum distended
unless perineum is well relaxed.
Allow the breech of the fetus to be delivered and wait with out
intervention till body is born up to the level of the umbilicus.
Delivery of the legs:

76
 Is assisted by splinting the medial thigh of the fetus with the fingers
positioned parallel to the femur and exertion of pressure laterally so as
to sweep the legs away from the midline.
Grasp the fetal bony pelvis using a cloth towel better moistened with
warm water. The fingers lie over the anterior superior iliac spine & the
sacrum. This avoids fetal soft tissue & visceral damage. Apply gentle
& steady down ward traction until the lower halves of the scapula are
delivered. No attempt should be made to deliver the shoulders & arms
until one axilla becomes visible.

Delivery of the shoulder attended by one of the two methods:

1. With the scapula visible the trunk is rotated in a way that allows the
anterior shoulder and arm to appear at the vulva & can easily be
released & delivered 1st. The body of fetus is then rotated in the
reverse direction in order to deliver the other shoulder and arm.
2. If trunk rotation was unsuccessful, the posterior shoulder must be
delivered 1st by elevating the trunk and the anterior shoulder by
depressing the body. The arm and hand usually follow spontaneously
and fetal back rotates anteriorly.

Delivery of the head (Methods)

1. Mauriceau Smellie viet (MSV) method: while the fetal body lies on
the palm of the hand & forearm, the index & middle finger applied
over the maxilla to keep head flexed. The two fingers of the other hand
are hooked over the fetal neck. Grasping the shoulder, gentle
downward traction applied until the sub occipital region become
visible under symphsis pubis. Gentle supra pubic pressure by an
assistant helps to keep the head flexed. The body of the fetus is then
elevated towards the mothers abdomen & delivery of the head
effected.

2. Modified Prague manoeuvre. This method is used when the back of

the fetus fails to rotate anteriorly. Grasp the shoulder of the back -
down fetus from below with two fingers of one hand while the other
hand draws the feet up over the mothers abdomen.

77
 3. Burns Marshall Manoeuvre
4. Bracht Manoeuvre - Only support after delivery of body
5. Forceps application for after coming head
o Could be applied electively or after MSV manoeuvre fail to
accomplish delivery of the head easily
o Forceps blades should be applied only when the after coming
head is brought into the pelvis and engagement allowed by
gentle traction supra-pubic pressure.
o Suspension of the body of the fetus with a towel helps to keep
the arm out of the way
o Pipers forceps are preferred choice

3. Breech extraction:
Is delivery of the fetus with no assistance from the mother. It serves as an alternative
to emergency cesarean section in desperate conditions.
Indication
Fetal distress in 2nd stage of labor
Cord prolapse or entanglement around the leg
Need for expedite delivery of 2nd twin
Precondition
Cervix must be fully dilated
There should be no mechanical obstruction or fetopelvic disproportion
of any degree
No uterine scar
The mother should not be grand multiparous
Technique: - Introduce one arm to the uterine cavity, grasp both feet of the fetus and
bring to the vagina by gentle traction. May need to do for each limb turn by turn but
never pull a single limb out of the vulva with out finding the other.
Make sure hand is not pulled out in place of the fetal leg.

Continue with traction until delivery of the hip, and

then follow as with assisted breech delivery.
4.4 Third stage of labor
Must be managed actively
Look for cervical and genital tract tear

78
4.5 Management of difficulties during VBD

Arrest of delivery of the legs

Pinnard manoeuvre:
Breech extraction
Extended arms & difficulty to deliver shoulder
Lovsets manoeuvre:

Nuchal arms
Attempt rotation in a direction to bring the arms anterior
Manual delivery like in Pinnard manoeuvre for the leg

Arrest of after coming head by incompletely dilated cervix

Try to slip manually
Try Bracht Manoeuvre
Duhressens incision

Arrest of the head at the pelvic inlet

Consider symphisiotomy
Abdominal Rescue (Zavanelli Manouever)
Perineal tears
Look for and manage appropriately.

79
 The Management of Ante partum Hemorrhage (APH)
Ante partum hemorrhage is bleeding from genital tract after the 28th weeks of gestation
up to delivery of the fetus.
The incidence is 2-3% of all pregnancies. In more than 50% of cases the cause is
unknown.
Avoid vaginal/ rectal examination In any pregnant women with APH
Mothers with APH should be managed at a site with operative and blood
transfusion facilities.

Causes of APH
A. Placental causes
1. Abruptio placentae
2. Placenta praevia
3. Miscellaneous: Vasa praevia, placenta membranacea, circumvalate
placenta, marginal separation of the placenta.
B. Non placental causes
1. Local causes (pathology of the cervix, vagina & vulva)
2. Heavy show
3. Uterine rupture
4. Bleeding disorder
C. Unclassified causes
APH viewed prospectively & retrospectively with insufficient evidence to
establish a definite cause.

Diagnosis
1. Clinical picture & predisposing factors
2. Ultrasound to localize the placenta and retro placental clot
3. Speculum examination 48 hrs to 10 days after bleeding stopped and after
ruling out major degree of placenta praevia
To diagnose local causes
To collect specimen for cervical smear
4. Double set up examination upon decision on termination.

80
Abruptio Placentae
Definition: Separation of the whole or part of the placenta from the normal implantation
site.
Predisposing factors: -
Hypertension;
Advanced age;
Multiparty;
Previous history of Abruptio placentae.
Multiple pregnancy;
Uterine Anomalies & Myoma;
Polyhydramnios;
Low socio economic status & poor nutrition;
Trauma;
Smoking; Cocaine use;

Table: Grades of Abruptio placenta

Clinical feature & Grade

Laboratory results I II III
Vaginal bleeding Slight Mild to moderate Moderate to severe
Maternal pulse Normal May be Elevated Elevated
Maternal BP Normal Maintained Shock
Uterine Irritability Usually present Tetanic & irritable Tetanic & Painful
FHR pattern Normal Fetal distress Fetal death
Maternal fibrinogen Normal 150-250mg% <150mg%
level

Placenta praevia
Definition: Placental implantation in the lower uterine segment within the zone of
effacement & dilatation of cervix or before presenting part.
Predisposing factors.
Scarred uterus;
Advanced age,
Multiparty,
Multiple pregnancy,
Erythroblastosis.

81
Classification: minor degree (type I) & major degree (Type II, III, IV)
Type I (Low lying) - Placenta is implanted in lower segment but doesnt reach to
internal Os
Type II (marginal) - (anterior & posterior) Placenta reaches the internal Os
Type III (partial) Placenta covers the internal Os partially
Type IV (totalis) The placenta covers the whole internal Os even at full
dilatation.

Management

General
Admission to a unit with operative and blood transfusion facility
Resuscitation as indicated
Avoid vaginal /rectal examination
Monitor fetal & maternal condition
Hct, Blood group & Rh determination
Prepare at least 2 units of cross matched blood
Anticipate PPH (Due to uterine atony or abnormally adherent placenta)
Decide on the final mode of management conservative versus aggressive
Delivery is indicated if heavy/recurrent bleeding
Fetal distress
APH at term
Emergency Cesarean delivery if sever hemorrhage or evidence of fetal distress
Double setup examination and decision on the mode of delivery depending on
the finding if mild hemorrhage and APH at term.
Specific
A. Abruptio Placentae (Moderate to severe)
Resuscitation
Restoration of the blood volume (crystalloid, colloid or blood)
Correction of Anemia
Correction of Acid base status
Prevention & correction of clotting defect
Monitor renal function
Investigation & observation
Vital sign hourly
In put and out put hourly
Hct 4 hourly

82
 Coagulation profile 4 hourly if DIC suspected
Clotting time
Fibrinolysin test

Delivery Indicated, in extensive separation (severe abruptio) & dead fetus

Vaginal - amniotomy & induction with oxytocin after Double set up

examination and excluding placenta praevia.
Cesarean section - for uncontrolled hemorrhage & other obstetric
indications
Hysterectomy: if uncontrolled hemorrhage
Couvalaire uterus is managed as sever case

Minor Abruptio placentae

Assess maternal status & background obstetric history
Assess fetal well being FHB, Biophysical profile, kick chart, fetal
growth.
Plan delivery If 37th completed weeks, fetal compromise, or ongoing
separation.
- Vaginal delivery if no contraindication for vaginal delivery.
- Caesarean- As moderate to severe (As above)
Couvlaire uterus
Oxytocin infusion
Hysterectomy reserved for cases of uterine atony & hemorrhage
unresponsive to uterotonic agents.
Placenta previa
Resuscitation depending on severity & clinical condition.
Monitor maternal and fetal condition
Investigation & Observation
o Hct
o Ultrasound
o Maternal condition vaginal bleeding & vital sign
o Fetal condition FHB & Kick chart daily, Biophysical profile once or
twice per week, fetal growth
Expectant Management: if bleeding is minimal and if it is a preterm pregnancy:
o Bed rest in hospital
o Monitor maternal & fetal condition
o Betamethasone 12 mg in 2 doses for 28-34 weeks gestation

83
 o Termination after 37 completed weeks of gestation

Delivery Consider the possibility of morbidly adherent placenta

Indication for termination
37 wks completed
Severe or recurrent hemorrhage
IUFD
IUGR
Fetal distress
Major congenital anomalies
Mode of delivery:
Vaginal after double set up examination and confirmation of type I or Type II
Anterior placenta previa provided in the absence of
severe bleeding & fetal distress.
Caesarean section- If
Major degree of placenta praevia (Type II posterior, III &
IV),
Fetal distress,
Severe uncontrolled hemorrhage.

Vasa praevia- Diagnosis: Fetal distress with no maternal vital sign derangement
Apt (alkalaine Phosphatase test) test for suspected fetal hemorrhage.

Management: Emergency cesarean section for viable live fetus

Determine hemoglobin of the neonate after birth

Local causes- Treat primary cause

APH of unknown cause-

Induction of labor after 37 completed weeks of gestation
Cesarean section indicated if severe bleeding or other obstetric indications.

84
 MANAGEMENT OF HYPERTENSIVE DISORDERS OF PREGNANCY
Hypertensive disorders of pregnancy remain to be one of the leading causes of maternal /
perinatal morbidity and mortality. Hypertensive disorders complicate 5-10% of all
pregnancies. Its etiology and patho-physiology remain enigmatic.

1.Classification
1. Gestational Hypertension: is the development of hypertension in a previously
normotensive pregnant woman after the 20th week of gestation (in the absence of
molar pregnancies)
2. Gestational Proteinuria: is the development of proteinuria in a previously non-
proteinuric pregnant woman.
3. Pre-eclampsia: Gestational proteinuric hypertension
4. ECLAMPSIA: Generalized convulsion or coma in a woman with preclampsia in
the absence of epilepsy or other convulsive disorders.
5. Chronic Hypertension is hypertension diagnosed in pre-pregnant state or prior to
20 weeks of gestation or persists beyond six weeks post partum.
6. Superimposed pre-eclampsia/eclampsia: is the development of
preeclampsia/eclampsia in a woman with chronic hypertension or renal disease.
Diagnosis is based on :
6.1. Elevation in systolic blood pressure of 30mmHg or diastolic 15mmHg or
more
6.2 a) is the development of proteinuria for the first time or worsening of
existing proteinuria.

b) Elevation in uric acid level 6mg/dl

7. Unclassified hypertension and/or proteinuria: Hypertension and/or proteinuria

found after 20 weeks of gestation and information is insufficient to permit
classification.

Pre-eclampsia

1.DIAGNOSTIC CRITERIA

85
A. Hypertension: is defined as
1. Blood pressure 140/90 mmHg. measured on two consecutive occasions
6 hrs or more apart. Or
2. Single blood pressure measurement 160/110mmHg.

Technique
1. Sitting position for ambulatory and semi reclining position for in patients.
2. Right arm used consistently
3. Measurement taken at the heart level
4. Korotkoff sounds IV & V recorded but the last Korotkoff sound is used for
diagnosis.

B. PROTEINURIA
- Qualitative: 1. 2+ Protein on reagent strip, or
2. 1+ reagent strip if SG (specific gravity) of urine is less
than 1030. Measurement done on two clean catch mid
stream urine collected 4hrs or more apart in the absence
of infection.
- Quantitative: 1. 24hrs urine protein 300mg
(definitive) or
2. Two random urine with protein concentration of 1gm/L,
collected 4 hrs or more apart.
C. EDEMA: Complicates up to 80% of normal pregnancies. Therefore it cant be used
as criteria for diagnosis of pre-eclampsia. However rapid development of
generalized edema or increase in weight >1kg/week can be a warning sign,
especially if coupled with other signs and symptoms of PIH.

Signs of severity of pre-eclampsia

Any one of the following evidences severe disease
1. BP systolic 160 or diastolic 110mmHg
2. Proteinuria: >5gm/24hrs or 3+ on two random urine specimen
3. Oliguria < 500 ml/24hrs
4. Deranged RFT or LFT
5. Thrombocytopenia
6. Pulmonary edema
7. DIC/HELLP syndrome
8. Imminent eclampsia/ Symptoms of severity
9. Eclampsia

86
 10. IUGR
Absence of the above manifestations put the patient into mild-category of preeclampsia /
pregnancy-induced hypertension.

INVESTIGATIONS
A. Base line tests: Hgb (HCT), platelet, U/A, 24hrs urine protein
RFT, LFT, Uric acid, Coagulation profile
Ultra sound (for fetal growth, and BPP)
B. Special tests:
Peripheral blood morphology in suspected HELLP syndrome.
Serum electrolytes in eclampsia
Chest x-ray,
Echocardiography in cases with Pulmonary edema and/ or congestive heart
Failure.
CT scan (MRI) in a woman with prolonged coma (to rule out intracranial
hemorrhage and cerebral edema) following eclamptic fit after controlling
hypertension & light sedation.

MANAGEMENT

Different strategies proposed for the management of PIH have shown mixed results.
Delivery remains the only definitive treatment. Therefore, delivery is generally indicated
in a woman at term with PIH of any severity and preterm with severe disease.

A. Objectives:

1. Prevent eclampsia
2. Preserve the health of the mother and fetus
3. Delivery of an alive, healthy & mature fetus.
B. Early detection and diagnosis
1. History
1.1. Primigravida or woman with a new partner
1.2. Past history of PIH
1.3. Family history of PIH
1.4. History of chronic renal disease or vascular disease.
2. Physical Examination
2.1. Weight measurement at each visit.
2.2. BP measurement at each visit.

87
 3. Investigation: Urine protein and uric acid.

C. Management
1. ambulatory management in Patients with:

1.1. Women with DBP between 90-100mmHg or SBP 140-160mmHg.

1.2. Proteinuria 1+ or less on dipstick or 24hrs urine protein
less than 500mg.
1.3.Compliant patient
1.4.No fetal jeopardy

2. Follow up:
2.1. Random urine protein twice per-week.
2.2. BP measurement twice per-week (self/nurse)
2.3. Daily fetal movement counting
2.4. Weekly ANC follow up.
The patient should report immediately if:
Sudden increase in weight, generalized edema involving the upper extremities and
face
Decrease in urine output,
Persistent headache
Blurring of vision,
Right upper quadrant or epigastric pain
Decreased fetal movement,
Vaginal bleeding
Convulsions or loss of consciousness occur

D. Hospital Management
1. Indication for admission: Patient deserves admission if criteria
mentioned in C 1 is not fulfilled.
2. Follow up:
2.1. Maternal
- Close follow up of the pregnant mother in search of imminent
signs/symptoms.
- Daily weight measurement
- BP every 6hrs.
- Urine protein every 48hrs

88
 - Hgb (hct), Platelet, RFT, LFT, uric acid, coagulation profile on
weekly basis.
2.2. Fetal
- Growth: clinical and serial ultra sound.
- Fetal Well-being: NST/ biophysical profile 2x/week (see protocol
on antepartum fetal well being testing).
- Daily FHR auscultation Daily fetal movement counting.( Kick
Chart)
3. Diet: Regular diet.
4. Anticonvulsant:
4.1. Indications:
a. All women with severe preeclampsia admitted for the first time.
- For the first 24-48 hrs. Parentral route should be used to
administer medication.
- Discontinue anticonvulsant if BP is controlled and expectant
management is planned.
b. All women with PIH going in to labor and delivery.
c. The first 48hrs post partum period.

4.2. Drugs
a. MgSO4 (Magnesium Sulfate)
- Loading dose: 4gm as 20% solution IV over 10-15 minutes
followed by 10gm as 50% solution IM (1/2 on each buttock)
- Maintenance: 5 gm every 4 hrs as 50% solution IM
- If convulsions recur, give 2gm IV in 50% concentration over 2
minutes.
- Monitor: RR every one hour (12/min)
DTR
Urine output every 4hrs (100ml/ hr)
- Reduce maintenance dose of MgSO4 by if signs of renal
derangement are present.
- Management of Mg+2 toxicity:

5. If DTR is depressed, discontinue MgSO4 and monitor the

patient closely.
6. If RR<12/min, give calcium gluconate 1gm as 10%
solution IV over 2 minutes (10ml)

89
 7. If signs of severe respiratory depression develop, transfer
the patient to ICU for mechanical ventilation.
b. Diazepam:
10mg IV bolus over 2 minutes
30mg/1000ml 5% D/W 30 drops/ minute.
Repeat 10 mg IV bolus if convulsions recur.
c. Phenytoin:
Is used for prevention of convulsion/recurrent convulsions
Continuous cardiac monitoring is essential during loading dose.
Loading dose 1gm IV over 20 minutes & maintenance 200mg
every 6hrs after 12 hrs of initial dose.
5. Anti-hypertensive:
5.1. Indication: for severe hypertension, to keep DBP <110mmHg.
Drugs:
Emergency treatment to control raised BP
a. Hydralazine (vasodilator)
Dose: 5 mg IV stat, repeat every 20 minutes until diastolic BP is <
110.
b. Nifedipine (calcium channel blocker)
Dose: 10mg sublingual, repeat same dose in 30 minutes
until diastolic BP is < 110.

c. Labetalol (B-blocker):
Dose: 5-15 mg IV push, every 10-20 minutes double the dose
(maximum, 300mg), and then 600mg PO six hourly if
conservative management is planned.

90
Maintenance antihypertensive treatment:
a. Methyldopa up to 4gm/ day P.O in divided doses adjusted with response
in controlling the BP.
b. Nifedipin 10-20 mg P.O every 6 hours
c. Hydralazine P.O.
d. Beta blockers

N.B. Anti-hypertensive use for the treatment of mild pregnancy induced

hypertension has no proven benefits.
6. Further Management Depends on:
6.1. Disease severity (maternal/Fetal condition)
6.2. Gestational age

7. Delivery:
7.1. All patients with severe preeclampsia and GA 34 weeks
Termination of pregnancy should be considered by
A.Induction if
7.2. Term, favorable cervix, no contraindication for vaginal delivery
7.3. Mature fetus, controlled maternal-fetal condition, no contraindication
for vaginal delivery with unfavorable cervix after ripening the cervix
B.Cesarean section: for obstetric indications.

7.4. Intrapartum care:

FHB monitoring every 15 minutes (preferably with CTG)
Maternal vital signs every 30 minutes 1 hr
Urine out put every 4hrs.
Shorten the second stage of labor
Prevent PPH (mange third stage actively using Oxytocin)
NB. Ergometrine use is contraindicated

8. Postpartum care
8.1 Continue anti-convulsant for 24-48hs-post partum
8.2 Closely monitor blood pressure & if hypertension persists beyond 6 weeks
post partum, the patient needs further work up / follow up.

91
ECLAMPSIA
Objectives of Management
Control of convulsion
Control of hypertension
Effect delivery once the patient is stable.

General Measures
The patient must be under constant observation
Avoid unnecessary external stimuli & injury
Prepare essential equipments and drugs for intervention (airway.
oxygen,
Suction, catheter etc)
Respiratory care
a. Avoid aspiration: Nurse patient in left lateral position.
Clear airway
Intubate when needed
b. Adequate oxygenation: Especially with repeated convulsions
c. Air way or mouth gag should be ready to prevent airway
obstruction by the patients tongue
d. Administer prophylactic antibiotic
Cardiovascular system
Measure BP every 15 minutes or use continuous BP monitor
ECG monitoring if available
Watch for signs of cardiac failure and fluid overload.
Renal system:
Catheterize the bladder
Monitor input and output
Determine serum electrolyte & acid base balance
Hematologic
Hct (Hgb), WBC, Platelet, coagulation profile

Specific Management
Anticonvulsant: see under D-4
Sodium amobarbital can be used in resistant cases.
Anti-hypertensive: see under D-5
Fluid therapy:
- 60-150ml/hr of 5% dextrose in normal saline

92
 - Replace extra fluid loss through-diarrhea, vomiting, diaphoresis
and blood loss
Delivery:Vaginal route preferred to abdominal route
In the majority labor starts spontaneously and is shorter
than normal delivery
If no signs of labor after stabilization & no contraindication
to vaginal delivery start induction with oxytocin.
Caesarian section: for obstetrical reasons
Shorten the second stage
Anesthesia for C/S: General anesthesia can be used.
Treatment of Complications:
a. DIC: -
Minimize trauma
Fresh whole blood and fresh frozen plasma
b. Acute renal failure
Restrict fluid intake to 500ml plus ongoing loss
Correct Electrolyte: watch for signs of hyperkalemia (ECG
& serum K+ level)
c. Pulmonary edema
Keep patient in propped up position
100% oxygen
Treat underlying cause
Restrict fluid in take to 2.5lit/day
IV loop diuretics 40-100mg (furesemide)
Aminophylline 240-480mg IV slowly

Post Partum management: see under D-7

Neonatal care: Neonate must receive skilled resuscitation and care and
or be transferred to neonatal intensive care unit.

Atypical Eclampsia:
Is occurrence of convulsions before 20th week of gestation or 48hrs after delivery. It can
occur up to two weeks postpartum. It should always be investigated to rule out other
causes of convulsion. Management is similar to eclampsia.

93
Chronic Hypertension:

Perinatal survival in low risk chronic hypertension is the same, as the general obstetric
population Hence Pharmacological therapy is indicated only in high-risk chronic
hypertension.
Criteria used to classify patients in to high risk category are:
Age >40yrs
Diabetes mellitus (class B-F)
BP>160/110mmHg
Hypertension>15 years
Renal disease
Cardiomyopathy
History of previous perinatal loss
Presence of lupus anticoagulant
Connective tissue disease
Drugs: to keep BP Between 140/90 160/105
Alpha methyl dopa: 1-4 gm in divided doses
Nifedipine: 20mg every 8-12hrs
Propranolol: 40 240mg in divided doses
Oral hydralazine: 50-200mg in divided doses
Combination of 2.1-2.4
Frequent ANC visits. All high-risk patients must be admitted.
Super imposed PE is an indication for admission.

94
 MANAGEMENT OF PREGNANCY
COMPLICATED BY DIABETS
Diabetes is one of the most common medical complications of pregnancy. Management
of Diabetes in pregnancy is a multidisciplinary approach and involves teamwork between
internist/ endocrinologist and neonatologist should be involved very early during
pregnancy and delivery.

CLASSIFICATION

Gestational diabetes mellitus (GDM) is defined, as any degree of glucose intolerance

with onset or first recognition during pregnancy. Ninety five (95) % of all diabetes during
pregnancy is gestational.
Pre-pregnancy diabetes: Diabetes, which is, diagnose prior to the onset of pregnancy.
This can be type 1 or type 2

Diagnosis
Gestational Diabetes Mellitus

Diagnosis of gestational diabetes mellitus requires undertaking oral glucose tolerance

testing

Overt diabetes during pregnancy

1. Symptoms of diabetes plus random plasma glucose concentration > 200mg/dL or

2. Fasting Plasma Glucose > 120 mg/dL or
3. 2-h PG > 200mg/dL during an OGTT

Gestational diabetes (GDM)

Universal screening for GDM is recommended since 50% of mothers with GDM may
not have identifiable risk factors. However, Patients with any of these factors should be
screened for GDM at first prenatal visit with OGTT
1. Maternal age > 35 years
2. Previous macrosomic infant (> 4000gm)
3. Previous unexplained fetal demise
4. History of Pregnancy with GDM
5. Strong immediate family history of diabetes

95
 6. Obesity (> 90kg)
7. Previous congenitally abnormal fetus
8. Glucosuria

SCREENING PROTOCOL FOR GDM

All women who are at risk of developing gestational diabetes should undergo screening
with 50 gm of glucose without any prior preparation. If the one-hour random blood
glucose level is 140 mg/dl or more the woman need to undergo a formal oral glucose
tolerance test.

The formal oral glucose tolerance test is undertaken after overnight fasting equal to 8-14
hours following three days of carbohydrate rich diet. OGTT is abnormal if two or more
values are equal to or above:

FBG> 105 mg/dl

1hr > 190 mg/dl
2h > 165 mg/dl
3h > 145 mg/dl

Treatment of GDM
Mainstay of management
Diet
Exercise
Monitoring blood glucose level
Initiate insulin if
Fasting glucose level is above 95 mg/dl or 2hours postprandial is more than 120
mg/dl

96
TREATMENT OF DIABETES IN PREGNANCY

Components to the treatment of diabetes in pregnant women:

Careful monitoring of blood glucose
Exercise (in GDM and type 2 diabetes)
Diet
Administration of insulin

Glucose monitoring

An ideal typical glucose monitoring involves capillary glucose checks on rising in the
morning, 1 or 2hr after breakfast, before and after lunch, before dinner and at bedtime.
In resource poor settings FBS and 2 hrs postprandial should be checked at least twice
weekly

Target glucose levels

Pre-meal glucose 60-95mg/dL
PP glucose <130mg/dL at 1hr or <120mg/dL at 2 hrs.
No significant hypoglycemia (glucose <60mg/dL) during the hours of sleep.
Exercise:

Using the upper body and walking appear to be more appropriate. Exercise should be
undertaken with the advice of a physician.

Contraindications to Exercise include:

PIH
PROM
Preterm labor
An incompetent cervix
Persistent 2nd or 3rd trimester bleeding
IUGR

Diet:

97
The optimal diet takes into account caloric intake, carbohydrate content and distribution
of meals throughout the day. The appropriate caloric intake depends upon the pregravid
weight with the following recommendations:
30 kcal/kg/day if the women is at ideal body weight
24 if 20-25% above ideal weight
12-18 if more than 50% above ideal body weight
36-40 if more than 10% below ideal body weight
Recommended distribution of calories
40-50% carbohydrate
20% protein
30-40% fat
Most programs recommend three meals and 3 snacks per day
Acceptable caloric distribution 10% of caloric at breakfast, 30% at both lunch and
dinner each and 30% as snacks.
A daily supplement of ferrous sulfate (300mg) and folic acid
(5 mg) is also recommended.

Insulin Therapy

Principles:
1. In GDM, initiate insulin therapy when FBS > 105mg/dL and 1hr pp blood glucose
concentration > 120 mg/dL on two or more occasions within a two week interval
despite attempted dietary control.
2. In the 1st trimester, reduce insulin dose by 10-25% to avoid hypoglycemia.
3. A typical insulin dose is 0.7 units kg in the 1st trimester, but this must be increased
progressively with gestational age.
4. A combination of short and intermediate acting insulin is necessary to maintain
glucose levels in an acceptable range.
5. Pre-meal doses of regular insulin are sufficient to keep 1 hr. pp blood sugar
<130mg/dL may result in hypoglycemia 4 hrs later. (e.g. Regular insulin before
breakfast often causes hypoglycemia at 11 A.M.) Snacks are essential in the late
morning, the late afternoon and prior to bedtime if regular insulin is used to avoid
postprandial hypoglycemia.
6. Ultra lente insulin can be used to provide a long-acting basal rate of insulin but
risks nocturnal hypoglycemia.

98
Obstetrics Management of Diabetes in Pregnancy

First Trimester
Obtain menstrual history for pregnancy dating
Obtain 24hr. creatinine clearance and total protein once as baseline and repeat
only if symptoms suggest diabetes nephropathy or possible pre-eclampsia.
Ophthalmologic examination
Ultrasound exam. For documentation of fetal viability and for confirmation of
dating.
Glycosylated hemoglobin levels to counsel diabetic women regarding the risk of
congenital abnormalities
Visit frequency should be guided by the adequacy of glycemic control and
patients compliance
During each visit, the patient should have routine evaluation of BP, weight gain
and glucosuria / ketonuria, blood glucose determination.

Second Trimester

Evaluate BP with special attention to whether the expected 2nd trimester drop has
occurred.
Careful measurement of Fundal Height to assess fetal growth
Maternal Serum Alpha Feto-Protein screening test at 16-18 weeks gestation
Ultrasound for assessment of fetal anatomy and for detecting malformations and
should include fetal echocardiography.

Third Trimester

Assess BP values frequently, because the likelihood of pre-eclampsia is

increased.
Serial ultrasound assessment for fetal growth, to identify LGA & SGA fetuses
every 4 to 6 weeks.
Initiate fetal surveillance (Fetal movement, NST, BPP, CST)

Fetal Surveillance In Type 1 And Type 2 Diabetic Pregnancies: Refer To Ante-

partum Evaluation

99
Timing and Route of Delivery

- An optimal time for delivery of most diabetic pregnancies is between

38 and 40 weeks.
- If a patient has maintained excellent glycemic control and all
parameters of fetal surveillance have remained normal, with no
obstetric problems dictating early delivery await the spontaneous onset
of labor.
- If early delivery is indicated, lung maturity should be assessed by
amniocentesis.

INDICATIONS FOR DELIVERY IN DIABETIC PREGNANCY

Fetal Maternal Obstetric

Non-reactive, positive CST Severe pre-eclampsia Preterm labour with failure of

tocolysis

Reactive (positive) CST, Mild pre-eclampsia, mature Mature fetus, inducible cervix
mature fetus fetus

Sonographic evidence of fetal Markedly falling renal

growth arrest function (creatinin clearance
<40ml/min)

Decline in fetal growth rate

with decreased amniotic fluid

38-40 weeks gestation

Route of delivery
Cesarean section is indicated only upon obstetric indications.

INTRAPARTUM GLYCEMIC MANAGEMENT

1. Insulin infusion method
a. Withhold the morning insulin injection
b. Begin and continue glucose infusion (5%DW) at 100ml/hr. throughout labour

100
 c. Begin infusion of regular insulin at 0.5 unit /hr. (5iu insulin in 1000ml of
5%D/W)
a. Begin oxytocin as needed
b. Monitor maternal glucose levels hourly.
c. Adjust insulin infusion as follows
Glucose /dL Infusion rate (units/hr)
< 80 Insulin off
80-100 0.5
101-140 1.0
141-180 1.5
181-220 2.0
> 220 2.5
2. Intermittent sub-cutaneus Injection Method
a. Give the usual insulin dose in A.M
b. Begin and continue glucose infusion (5% DW) at 100ml/hr
c. Begin oxytocin if needed
d. Monitor maternal glucose hourly
e. Administer regular insulin in small (2-units) doses to maintain glucose 80-
120 mg/dL
Postpartum
GDM - No therapy required
Type 1 One third to one-half of antepartum daily dose, 60% of pre-
pregnancy dose
Type 2 pre-pregnancy insulin regimen, or diet controlled, or Oral
hypoglycemics can be restarted.

POSTPARTUM MANAGEMENT:
- Screen for and manage Hypoglycemia In the neonate. It occurs in
about 40 % of the offspring of diabetic or gestational diabetic mothers.
- Immediately after delivery, measure Blood Glucose Level to ensure
that the mother no longer has hyperglycemia (FPG <115mg/dL, 1-hr
pp<140)
- A woman with GDM should be able to resume a regular diet. However
she should continue to measure BG for few weeks, especially if she
was diagnosed early in gestation or required insulin during the
pregnancy

101
 - At 6-8 weeks postpartum, or shortly after cessation of breast-feeding,
all women with previous GDM should undergo a 2hr 75-g OGTT.

Criteria for the diagnosis of DM

Normoglycemia IFG & IGT DM

FPG <110 mg/dl FPG> 110 and FBG > 126
<126mg/dL (IFG)
2h PG < 140 2h PG > 140 and < 200 2h PG > 200
(IGT)
- Symptoms of DM and causal
plasma glucose conc. > 200

- If the results of the postpartum OGTT are abnormal, refer the

patient to a diabetic unit.
- Advise women with normal postpartum OGTT values of their high
risk to develop
1. GDM in subsequent pregnancies (up to 66%) and /n
2. Overt diabetes over the next 10-15years (50-75%)
- Encourage attaining and maintaining ideal body weight in an effort to
reduce the risk of developing diabetes in the future.
- If glucose levels are normal postpartum, reassessment of glycemia
should be undertaken at a minimum of one year.

RECOMMENDATIONS ON CONTRACEPTIONS
- Barrier methods: are safe and without metabolic side effects
- Women with preexisting diabetes, who do not have serious vascular
disease, may be prescribed either the lowest dose combination or
progestin only contraceptives under medical supervisions.
- Neither DMPA nor Norplant is recommended as 1st line methods of
contraception in woman with diabetes
- Permanent methods of contraception are ideal if family size is
complete.

PRECONCEPTION CONTROL PROTOCOL IN OVERT DIABETES

History and physical examination
Hypertension Control BP ideally < 130/80 mm

102
 - Stop smoking
Retinopathy - Ophthalmologic consultation
Rule out ischemic disease
- ECG, exercise test if indicated
Renal - Serum creatinin concentration and total protein to creatinin ratio
- Urinanalysis and culture
- Serum creatinine concentration > 2mg/dL is a potential
contraindication for pregnancy
Thyroid - Serum thyrotropin, TSH, T3 & T4

Diabetes - Achieve diabetic control before conception

- If HbA1C is greater than 4 standard deviations above the normal mean
for women without diabetes, intensive insulin therapy is warranted.
- Self blood glucose monitoring at least 6 times a day (before & one hr.
after each meal)
- Preconception goals include pre-meal blood glucose concentrations of
70-120 mg/dL and 1 to 2 hr. pp below 150 mg/dL.
- Repeat HBA1Cone month after initiation of program
- Retest every month until target HbA1Cvalue achieved. Once in target
range, permission granted to become pregnant on the next cycle.
- A pregnancy test 1 day after missed period will confirm pregnancy.

Relative contraindications to pregnancy

- Ischemic heart disease

- Active proliferative retinopathy (untreated)
- Renal insufficiency: creatinine clearance <50ml/min.
Serum creatinine > 2.0 mg/dL or heavy proteinuria (>2g/24hr.)
- Uncontrolled HPN: BP>140/90 mmHg despite treatment
- Severe gastroenteropathy: nausea/vomiting, diarrhea

103
 MANAGEMENT PROTOCOL FOR POST PARTUM HAEMORRHAGE

Postpartum hemorrhage (PPH) is defined as:

Blood loss in excess of 500ml following vaginal delivery and 1000ml following
cesarean section or
10% drop in Hct secondary to blood loss after delivery. Or
Clinically it may be evidenced by change in vital signs, pallor and the need for
blood transfusion.

Classification:
Primary PPH: hemorrhage occurring with in the first 24hrs of delivery.
Secondary PPH is vaginal bleeding occurring 24hrs after delivery through 6
weeks postpartum.

Incidence and Significance:

PPH complicates approximately 5-8% of vaginal deliveries. Hemorrhage is one of the
five major causes of maternal death and accounts for about 25% of this death worldwide.

Causes of PPH
Early or primary PPH
Uterine atony
Retained placenta
Genital tract lacerations
Uterine rupture
Uterine inversion
Coagulopathy

Late/ Secondary PPH

Endometritis
Placental site subinvolution
Retained placenal fragments
Coagulopathy
Gestational choriocarcinoma
Others (submucous myoma, cervical cancer, Placental polyp)

104
Risk factors for PPH

1. Uterine atony:
Uterine over distention
Polyhydramnios
Multifetal gestation
Macrosomia
Grande multiparity
General anesthesia (halothane)
Previous history of PPH
Obstructed or prolonged labor
Chorioamnionitis
Induction / augmentation of labor(Use of oxytocin)
Couvellairs uterus (uterine apoplexy)
Retained placenta

2. Lower genital tract laceration

Instrumental delivery
Episiotomy
Fetal macrosomia
Precipitate labor
Breech extraction
Delivery through undilated cervix

3. Retained placental tissue

Mismanagement of the third stage
Succenturiate lobe
Morbidly adherent placenta
Uterine anomalies

4. Uterine inversion
Faulty cord traction
Fetal macrosomia
Fundal placentation
Morbidly adherent placenta
Uterine anomalies

105
 5. Coagulopathy
Abruptio placentae
Preeclampsia/eclampsia
Sepsis
Amniotic fluid embolism
IUFD
Excessive blood loss
Drugs
Hereditory disorders

Diagnosis : is mainly clinical

Excessive bleeding
Hypotension, Tachycardia,/ hypovolemic shock.
Atonic uterus with /without placental expulsion
Post partum drop of Hct by 10%

Bleeding could be massive (external or concealed as much as 1000ml of blood in

distended uterine cavity) or moderate over a prolonged period resulting in excess blood
loss in few hrs. Hence close observation in the Fourth stage of labor with serial
monitoring of vital signs, uterine palpation and assessment of vaginal blood loss is very
essential.

IV. MANAGEMENT
General

1. Assess risk factors for PPH antepartum or early intrapartum

2. High risk patients should have blood group typed and possibly cross-matched
upon arrival.
3. Shout for HELP! Once PPH has set in. Treatment of PPH is teamwork
4. Palpate the uterus and massage if atonic
5. Open at least two intravenous lines for fluid replacement
6. Take blood sample for group and Rh determination and cross match.
7. Evacuate the bladder.
8. Supplement oxygen administration (5 l/min of 100% oxygen) and placement of
an indwelling urinary catheter
9. Careful documentation of vital signs, input-output and drugs used

106
 10. Further management depending on the cause

Fluid administration
Three (3ml) of crystalloid solution is infused for each ml of estimated blood loss
Attempt should be made to keep systolic blood pressure above 90mmHg and
urine out put over 0.5ml/kg/hr.
When available colloids such as Dextran or Hemacel can as well be used.
Since colloids can influence blood typing specimen should be collected before
starting infusion.

Blood Transfusion

Blood transfusion is indicated If no improvement or only transient improvement in vital

signs and urine output occurs with the initial infusion of 3000ml of crystalloids.

Final Treatment depends on the underlying cause

A. Uterine atony
I. Massage the uterus.
I. Evacuate the bladder
II. Medical therapy with the following drugs

Drugs Methods of Administration Contra-indications

Oxytocin: 20units/ in 1000ml of N/S or R/L
60drops/min(>125ml/hr) IV none
(Not more than 3lits)

Methylergometrine 0.2mg repeated Q Hypertension

Or ergometrine 2-4 hrs im or iv Cardiac disease
(Maximum 5 doses)

15-MPGF2 0.25mg im every 15-90 min Active cardiac, renal

(Maximum 8 doses) or hepatic disease
Bronchial asthma
Can be given in combination with
oxytocine

107
If bleeding continues:

Explore the uterine cavity, check placenta again for completeness, inspect the cervix and
the lower genitalia for laceration and manage accordingly

If bleeding continues

In spite of the above management, perform bimanual compression of the uterus.

Alternatively, compress the abdominal aorta until surgical intervention is amenable.
These procedures will buy time for surgical intervention and might be life saving.

Indications for Surgical intervention.

Uterine atony when medical therapy is unsuccessful
Uterine rupture
Factors to be considered include:
*Patients desire for future fertility
*Parity
*The degree of hemorrhage
*Homodynamic stability of the patient
*Skill and experience of the surgeon

Surgical management

1.Uterine artery ligation or/and utero- ovarian artery ligation:

In the absence of uterine rupture and/or broad ligament hematoma

2.Hypogastric artery ligation:

Experienced surgeon
Uterine rupture and broad ligament hematoma.
Hemodynamically stable patient

3.Emergency Hysterectomy
When conservative measures fail or future fertility is not considered
Pelvic pressure pack in persistent post hysterectomy hemorrhage

108
B. Lower genital tract laceration
Bleeding continues despite a well-contracted uterus.
Explore the cervix, vagina, perineum and episiotomy site and manage
accordingly.

Vulvar hematomas (vulvar, vaginal and episiotomy site)

-If small (<5cm diametre)
Observation, Ice pack, Analgesic
-Larger in size
Evacuation, ligate the bleeding vessel
N.B: The cervix should be inspected routinely in all difficult (instrumental,
destructive, difficult breech) deliveries.

D. Retained placenta (see protocol on normal delivery)

F. Uterine inversion: is a rare cause of PPH but associated with high rate of maternal
mortality and morbidity

Diagnosis: Clinical
Complete inversion: the uterus is inverted inside out and can easily be seen.
Incomplete inversion: depression or defect of the uterine fundus on abdominal
examination and easily palpable fundus vaginally
Treament
Resuscitation with fluids/blood
Replace the uterus manually immediately if it fails replace it under anesthesia
Start oxytocin drip and discontinue relaxing agent as soon as the uterus is
replaced
If placenta is undelivered, replace the uterus first and remove the placenta
manually with IV infusion in situ.
Surgical intervention may rarely be indicated, if manual replacement fails

109
Abnormal placentation or morbidly adherent placenta (placenta accreta, increta,
percreta)

Diagnosis:
The placenta doesn't have cleavage line from the decidual plate
The placenta will be retained and there may not be bleeding unless has already
been manupilated
The abnormality may involve all of the cotyledons (total), a few to several
cotyledons (partial) or a single cotyledon (focal)

Treatment
Generally, up on attempting removal of a retained placenta if there is
no cleavage line the procedure has to be abandoned not to inflict
severe hemorrhage
Emergency hysterectomy is the safest treatment
Curettage and /or hemostatic sutures may be considered in focal
adherence

Coagulopathy
Continuous bleeding from multiple sites with deranged coagulation profile
Can cause or exacerbate PPH or coagulopathy may be a result of PPH
Lab investigations: platelet count, PT, PTT, fibrinogen level, clotting time
The main stay of treatment is the resolution of the primary disorder
Give fresh whole blood or blood products (fresh frozen plasma, packed RBC,
cryoprecipitate or platelet concentrate based on the major disorder recognized)

Late PPH
o The commonest cause is Infection
o Peak occurrence in first through second postpartum week
o Ultrasonography to rule out retained placental tissue
o Tissue specimen retrieved from curettage should be subjected for
histopathology
Treatment should include:
o Uterotonic agents
o Broad-spectrum antibiotics if infection is suspected
o Uterine curettage if retained tissue

110
Preventive measures for PPH
Identify high risk factors for PPH
Iron supplementation during pregnancy to build up iron store in all
pregnant women and treat anemia in pregnancy
Active management of third stage of labor (see protocol on labor
and delivery)
Careful management of the third stage and avoid unnecessary
interventions at delivery
Family planning/child spacing

111
 VAGINAL BIRTH AFTER PREVIOUS CESAREAN DELIVERY (VBAC)

For many years scarred uterus was felt to contraindicate labor out of fear of uterine
rupture. Obstetric practice worldwide has been dominated by the dictum "once a
cesarean, always a cesarean" for nearly 70 years until it was replaced by the statement
once a cesarean, always a scar".
This concept has been changing gradually over the last 30 years. VBAC/ TOL (Trial of
labour)* has been accepted as one-way to lower the over all-cesarean delivery rate.

VBAC/TOL
Benefits Risks
Less postpartum febrile morbidity uterine scar dehiscence (<1%)
and less need for transfusion Failed VBAC entails:

Reduced anesthesia risk a. Increased fetal and maternal

Shorter hospital stay postpartum morbidity

Early and smooth mother-infant interaction b. Increased cost of care and

Less cost c. prolonged hospital stay

No increase in perinatal morbidity and

Mortality

VBAC should only be conducted in setup with 24 hrs comprehensive obstetric

service and blood transfusion.

SELECTION OF CANDIDATES FOR VBAC/TOL

One previous low transverse caesarian section, low vertical caesarian section
No clinical evidence of cephalo - pelvic disproportion
Singleton pregnancy
No malposition and malpresentation
Myomectomy with out entry in to the endometrial cavity.
No other uterine anomalies, scars or previous uterine repair for rupture
Estimated fetal weight < 4000gms

112
ABSOLUTE CONTRAINDICATIONS FOR VBAC/TOL
Obvious clinically contracted pelvis
Prior complicated caesarian section (extensions), classical or T- shaped incision
Prior uterine repair for rupture and transfundal surgery
Multifetal gestation
Any malpresentation or malposition
Estimated fetal weight > 4000gm
Medical or surgical condition that preclude vaginal delivery

Before conducting VBAC/TOL assure the ready availability of staff and medical
resources to monitor labor in the active phase and to perform emergency surgery such
as caesarian section or handle uterine rupture. Adequate blood bank service is vital.

MANAGEMENT
(A) Antenatal

Similar as any high risk pregnant mother with

1. Review medical records and emphasize on:
Indication for previous caesarian section
Type of surgery and Post-operative course
Clinical pelvic assessment at term
Estimation of fetal weight (clinical, ultrasonography)
2. Counseling
Assess all individual risks, emphasize on benefits of VBAC/TOL
Document the counseling process and plan of management on
prenatal records.
Get informed consent

N.B. Mothers should be instructed to come to hospital at the onset of labor or if any
complications arise without delay.

(B) Intrapartum
First stage:
Latent phase:
Admit to labor suite, evaluate parturient promptly
Update investigations and prepare two units of x-matched blood.

113
 Allow Normal activity with no restriction.

Active phase:
Reevaluate parturient
Follow progress of labor using partograph properly.
Closely monitor FHR every 15 minutes or
Use continuous electronic monitoring to pick abnormal FHR pattern
Monitor Uterine contraction every 30 minutes
If available, use Intrauterine-pressure catheters
Closely watch for evidence of scar dehiscence like abdominal/uterine
tenderness vaginal bleeding, FHR abnormality, and maternal vital sign
derangement

Analgesia:
Use epidural anesthesia or
Pethidine

Second stage: -
Avoid prolonged second stage and assist delivery as any other case.

Third stage: -
Deliver placenta by CCT.

Look for excessive vaginal bleeding, signs of hypovolemia after delivery of the
baby and placenta.
Avoid routine post- delivery uterine exploration.
If there is excessive vaginal bleeding or signs of hypovolemia, explore the uterus
and the whole of the genital tract.
If defect communicating with peritoneal cavity is detected, do emergency
laparotomy and perform repair, repair with tubal ligation or hysterectomy as
indicated.
DECLARE FAILED VBAC /TOL
If the alert line is crossed for two hours

114
 MANAGEMENT OF Rh ISOIMMUNISATION

Incompatibility with respect to D-antigen is the most common cause of serious hemolytic
disease of fetus and the new born. 15% of the population is believed to be Rh-negative.
About 60% of individuals with Rh-positivity are heterozygous while 40% are
homozygous. Patients with Du positive are also considered as D+ve.

Fetomaternal hemorrhage (FMH):

Complicates about 15-50% of births. Large bleeds (> 30ml) occur in 1% of cases.
The following conditions may increase risk of isoimmunization:
o Cesarean delivery Multiple gestation
o Placenta praevia/ Abruptio placenta Manual removal of placenta
o Intra uterine manipulation Amniocentesis
o External cephalic version Ectopic pregnancy
o Abortion (risk is high beyond 6 weeks of gestation)

Management Of Unsensitized Rh-Ve/ Du-Neg. Pregnancy

Indirect Coombs test at initial visit Negative.

1.Father Rh +ve or unknown status.
Repeat Coombs indirect test at 28 weeks of gestation and give 300
g of Rh. immune globulin if test result is negative.
Check Rh status of new born at delivery
o If Rh +ve /Du +ve or unknown status give 300g immune
globulin to mother.
o If Rh ve prophylaxis not indicated
2. Father Rh ve /paternity certain.
No prophylaxis needed.
Spontaneous or induced abortion.
300 g Rh immunoglobulin should be administered.
Ectopic pregnancy prior to 12 wks.
Give 50 g Rh immuneglobulin
After 12 wks
300g Rh- immunoglobulin should be given.
Prophylaxis: administer 300 g Anti D- iommunoglobulin
Amniocentesis: - If delivery is delayed > 72 hrs
2nd or 3rd trimester bleeding.

115
 Molar pregnancy
Abdominal trauma
Chorionic villus sampling

Management Of Rh Sensitized Pregnancy

Consider the following points.

Asses past reproductive performance (High risk of recurrence)
Ascertain gestational age
Indirect Coombs test in titer positive >1:8

A. First trimester: follow the pregnancy with antibody titer every four (4) weeks

B. Second trimester: Follow with antibody titer every two-four weeks

Amniocentesis and management using the Liley chart
Liley zone I or lower zone II
Repeat amniocentesis every 4 wks.
Delivery when lungs mature/at term
Liley middle or upper zone II
Repeat amniocentesis every 2 wks. and if trend down ward repeat
every 4 wks.
Trend upward or flat apply the same treatment as in zone III.
Liley zone III
Based on gestation age should either be delivered or receive
intrauterine transfusion.
Steroids should be administered if termination before 34 weeks
of gestation is considered
c. Intrapartum care:
Close monitoring of the FHR
Avoid traumatic delivery
Transfer the neonate for blood group determination and neonatal care.
NB. Neonate may require exchange transfusion

116
 Amenorrhoea
Amenorrhea like any other menstrual disorders is essentially a symptom of local,
systemic or constitutional disorders.

Primary amenorrhea is considered if menstruation dont appear at the age of 16 in the

presence of secondary sexual characteristics or at the age of 14 in the absence of
secondary sexual characteristics.

Secondary amenorrhea Absence of menses for three cycles in oligomenorrhic woman

or for six months in a woman with regular cycles.
The incidence of primary amenorrhea is 2.5%, while that of secondary amenorrhea is
quite variable. The evaluation of amenorrhea attempts to segregate causes of amenorrhea
into different orderly compartments.
Compartment I
Disorders of out flow tract
Compartment II
Disorders of the ovary
Compartment III
Disorders of the anterior pituitary
Compartment IV
Disorders of the hypothalamus, cortex

Evaluation
Amenorrhea can occur due to iatrogenic conditions like hysterectomy, Radiation due to
physiological conditions such as pregnancy, lactation or menopause. Complete history
and physical examination is necessary to establish the physical presence of normal
genitalia and to rule out the presence of significant concomitant diseases.

1. History:
Detailed menstrual history
Presence of abnormal growth and development
Evidences for psychological dysfunction and emotional stress
Family history of apparent genetic anomalies
Presence of inappropriate galactorrhea
Excessive weight gain or loss
Past medical or surgical history
Chronic medical illnesses like TB,

117
 Metabolic disorders
Radiation exposure
Drug history
History of curettage, previous uterine surgeries

2. Physical examination
Complete Physical examination with especial emphasis on
Blood pressure
Weight and height measurement
Thyroid status
Presence or absence of galactorrhea
Signs of acromegaly and Cushing syndrome
Presence of abnormal reproductive tract
Secondary sexual characteristics
Abnormal hair growth
Neurological examination and determination of visual field

Steps for evaluation

Woman who have normal pelvic examination and secondary sexual
characteristics
Step I
1. Measure serum TSH and prolactin
2. If TSH is elevated consider treatment with thyroxin
3. In the presence of hyper prolactinemia with or without gacactorrhea consider
Coned down and lateral x-ray of sella turcica Or
CT scan if available
Consider Medical treatment with bromocryptin or surgical treatment as
indicated
4. Progesterone challenge test
Oral medroxy progesterone acetate 10mg daily for 5 days or progesterone
100-200mg im as single dose, anticipate withdrawal bleeding 2-10 days
after the last dose.
Norethesterone (Primolut N.) 10mg /day for 5 days
Or
Norethesterone (Primolut N.) 250 mg IM stat

118
 Step II
4. If No withdrawal bleeding after the progesterone challenge test
Administer cyclical estrogen- progestin therapy
If no withdrawal bleeding
Consider Defect in compartment I

Step III

Withdrawal bleeding after cyclical estrogen progesterone therapy,

Do serum gonadotrophin (FSH, LH) assay.
If gonadotrophins are high (Hypergonadotrophic state)
- The problem lies in compartment II
- Direct investigation towards ovarian cause
(Refer compartment II disorders)

2. If gonadotrophins are normal/low ( Hypo / Normo gonadotrophic state)

- The problem is in compartment III and IV (refer compartment III, IV

disorders)
- Continue investigation to exclude intracranial lesions
- X-ray of sella turcica
- CT scan
- Investigate for other systemic diseases if all these investigations turn out to be normal
Consider hypothalamic dysfunction.

COMMON SPECIFIC DISORDERS WITH IN COMPARTMENTS

Compartment I

A. Congenital out flow disorders

- Imperforate hymen
- Transverse vaginal septum
- Mullerian agenesis
- Androgen Insensitivity Syndrome (AIS)
Diagnosis:
Physical examination
Buccal smear for barr bodies/ Kariotyping /chromosomal analysis

119
U/S, laparascopy: to evaluate the internal genital organs, adnexal structures, presence of
male gonads etc.

B. Acquired Outflow tract disorder

- Ashermans syndrome
Suggestive history
HSG
Hysteroscope
-Cervical, vaginal scarring
Management: is mainly surgical
Imperforate hymen: Cruciate incision
Transverse septum: Excision
Mullerian agenesis: Counseling with or without corrective surgery
Asherman Syndrome:
Dilatation and Curettage coupled with insertion of Foley catheter or IUCD
Hystetrescopic resection
Hormonal treatment
AIS: Gonadectomy after complete puberty

120
 Compartment II

A. Gondal dysgenesis
- Counseling
- HRT after early diagnosis
- Gonadectomy if male gonad

B. Premature ovarian failure

Diagnosis: Suggestive history
- Karyotyping for y chromosome in patients younger than 30
- Evaluate for autoimmune disorder
- Screen for metabolic/endocrine disorder
Management: Counseling with or without HRT
C. Polycystic ovary
Diagnosis: Suggestive clinical manifestations
- Serum LH (elevated), FSH (low, low-normal) ratio of 2:1
- Raised androsteinidione
- Laparoscopy
- Hyperinsulinemia
Management: OCP
Ovulation induction
Laparascopic drilling
C. Congenital adrenal hyperplasia
Diagnosis: Ambiguous genitalia /virilization
- Primary amenorrhea
- Hypertension
- Elevated serum progesterone/17-OH progesterone
- ACTH stimulation test, 17-keto steroids
Compartment III

- Sheehans syndrome
- Pituitary tumors, Cushings syndrome, Hypothyroidism
Management: is cause specific

Compartment IV
Diagnosis: is usually by exclusion
Consider: hypothalamic disorders (craniopharyngioma, kallmans syndrome etc)

121
 Central (Cranial) disorders
Physical, Emotional disorders,
Chronic illnesses
Nutritional disorders etc.
Management: Cause specific
Psychotherapy
Surgery

122
 The evaluation of urinary incontinence in female
Urinary incontinence (UI) is defined as involuntary loss of urine that is objectively
demonstrable and is a social and hygienic problem.

Because of anatomic and embryological close relationship and common supportive

structures combination of anal incontinence, UI and utero-vaginal prolapse are common.
Causes are various and range from simple urinary tract infection to more complex
conditions, which are difficult to diagnose and treat.

Each woman with a complaint of UI (Irrespective of severity) deserves an appropriate

evaluation before treatment.

Classification of UI
A. Extra urethral
i. Congenital - Ectopic Ureter
- Bladder extrophy
ii. Acquired - Fistulae
- Vesical
- Ureteric
- Urethral
- Combination

B. Trans Urethral
1.Genuine stress incontinence (GSI)
- Anatomic hyper mobility of bladder neck is urethra
- Intrinsic sphincter dysfunction
- Combination
2. Detrusor over activity
- Idiopathic detrusor instability
- Neuropathic detrusor hyperreflexia

3. Mixed (combined GSI and Detrusor over activity)

4. Overflow incontinence
5. Urethral diverticulum
6. Congenital urethral abnormalities (e.g. Epispadias)
7.Uninhibited urethral relaxation (urethral instability)

123
C. Functional and transient in continence (DIAPPERS)

Delirium
Intention
Atrophic urethritis/ vaginitis
Pharmacological cause
Psychological cause
Excessive urine production
Restricted mobility
Stool impaction
Neurologic diseases that affect the normal neurologic axis causing UI

Diagnosis: Complete history and physical examination to:

Clarify the patient symptoms
Objectively demonstrate loss of urine
Revise the urinary diary
Determine the type of UI using clinical testing
Identifying those who require more sophisticated tests

Laboratory investigation:
The following can be considered based on the clinical diagnosis
U/A and urine culture (urine cytology as appropriate)
Measurement of post-void residual urine
U/S
Simple cystometry
Cystourethrography
IVP
Dye test
EMG (electromyography)
Multichannel study

D. Clinical tests
Stress test- for objective demonstration of urinary leakage with stress.
Examination is done with subjectively full bladder or instillation of 300 ml sterile
saline
Position. Lithotomy / standing with feet spread out to shoulder width.
Patient asked to cough repeatedly.
Demonstrate for the presence of urinary leakage simultaneously with coughing
(trans urethral)

124
Pad test- objective demonstration of UI for patients who have not demonstrated leakage
in the stress test.
Pre-weighted perineal pad used and patient completes a 1 hr series of preset
maneuvers, then pad is reweighed. An increase in weight by > 2gm is indicative
of urinary loss.
Q-tip test (office cotton swab test): Measurement of the urethral axis as a method to
assess the degree of mobility of urethrovesical function.
Lubricated sterile cotton swab is inserted into the urethra up to the level of bladder
neck
Patient is asked to cough/strain
Maximum deflection of the swab stick from the horizontal measured using a
simple plastic protractor.
A maximum straining angle >300 is generally taken to represent the presence of
Urethral hyper mobility.

Post Voidal residual Urine Measurement is important to identify: -

Co-existence of voiding problem with UI
Large residual volume decreases functional bladder capacity causing bladder
distension and leading to stress incontinence, overflow incontinence or provokes
uninhibited
Detrusor contraction.
Stagnant urine pool causes recurrent UTI
Should be measured after a spontaneous voiding
Residual volume >200ml (measured at least on two occasions) is
pathological.

Urinalysis / Culture: to diagnose cystitis

Dye test - Diluted methylene blue for- for small VVF

- Indigo carmine IV 5ml for uretero vaginal fistula.
Urodynamic studies: to identify and quantify the etiologic factors contributing to
lower urinary tract dysfunction.
Pressure volume relation of the bladder is measured
Assesses bladder sensation, bladder capacity, bladder compliance and detrusor
activity.

125
Simple cystometry: - Crude diagnostic modality
Fill the bladder is filled with normal saline, 50ml increments (By gravity), using
a catheter attached to syringe with the piston removed.
A rise in the fluid level by > 15 ml in the absence of intra abdominal pressure
associated with urgency or leakage is suggestive of detrusor instability.

Multi-channel Urethrocystometry: measures bladder, urethral and abdominal

pressures
The bladder is filled at a standard rate of saline (50-100ml/min) and the patients
sensations are recorded and correlated with the subtracted detrusor pressure.

Normal values are:

Residue urine <50ml
First desire to void 150- 250ml
Cystometric capacity 400- 600ml
Max-detrusor pressure <15cm H2O
Max-detrusor pressure during voiding <70cm H2
Ultrasonography:- To visualize the bladder neck during rest, coughing and valsalva
maneuver.
Bladder neck mobility can be visualized by vaginal, rectal and perineal
ultrasonography.
Hyper mobility is defined as a bladder neck descent >1cm during valsalva.

Summary of the step wise evaluation of a patient with Urinary incontinence

Stepwise evaluation helps the treating physician to formulate a presumptive diagnosis

and initiate treatment starting from simple, less expensive and less invasive method to
more complex, expensive and invasive methods.

Step I
Patient history and P/E
U/A including culture
Post-void residual urine
Urinary diary

126
 Step II
Perineal pad test
Q-tip test
Bead-chair cyst urethrography
Ultrasound-vaginal/perineal
Simple single channel cystometry (electronic/non electronic)

Step III
Complex multi channel uro-dynamics

Some indications for Step III evaluation

Complicated History
Inconclusive studies from step II
Before surgical treatment for stress incontinence
Urge incontinence not responsive to therapy
Previous surgery for stress incontinence
After pelvic radiation and radical pelvic surgery
Those with neurologic disorder

Treatment: Depends on the specific pathology diagnosed

127
 Algorithm for Assessment of UI

Incontinence
1. NO Objectively

Yes

Mid Stream urine culture

_ +
Antibiotics

History
P.V Physical Exam PR

Abdominal mass Fecal compaction enema

2 Fistula

Bladder
Palpable Not Palpable

3 Evaluate voiding Examine with full bladder

difficulty

GSI

Urathrotomy Catheter
No Yes

Cystomety
4 Rx as
Detrussor
Stable Unstable
1= No objective demonstrate incontinence
2= True incontinance 5 GSI
3= Over flow incontinence with BOO
4= Detrusor instability 6
Detrussor
5= Genuine stress incontinence instability stress
6= Combined both DI and GSI

Surgery Exercise Estrogen for elderly

Antispasmodic & adrenerg: C drugs

128
 THE MANAGEMENT OF GESTATIONAL
TROPHOPLASTIC DISEASES (GTDs)

GTDs include the tumor spectrum ranging from benign hydatidiform mole to the most
metastatic malignant tumor, choriocarcinoma. The disease is relatively uncommon in its
occurrence. The incidence varies with racial and environmental factors.

CLASSIFICATION
Histologic classification
Hydatidiform mole (HFM)
Invasive mole
Choriocarcinoma
Placental site Trophoblastic Tumor (PSTT)
Clinical classification (based on HCG regression and clinical findings)
Gestational Trophoblastic Disease (GTD)
- Covers all entities mentioned under the histological classification
Gestational Trophoblastic Tumor (GTT)
- There is evidence of invasive mole or choriocarcinoma.
Metastatic Trophoblastic Disease (MTD)
- There is evidence on clinical grounds of invasive mole or
choriocarcinoma extending beyond the confines of the uterus.

Diagnostic Approach

History and Physical Examination

HFM accounts for 80% of GTDs the main clinical features are:
Vaginal bleeding in 97% of cases
Uterine size is greater than the gestational age by date in 50% of cases
Techa-lutein cysts in 50% of cases (size >6cms)
Pregnancy induced hypertension (PIH) in 27% of cases
Hyperemeisis in 25% of cases
Hyperthyroidism in 7 % of cases
Malignant GTD may present with
Abnormal uterine bleeding, or delayed post partum hemorrhage
Vaginal or sub urethral tumor deposits.

129
 Cerebrovascular accident (particularly in a reproductive age woman),
Chest symptoms (pain, cough, hemoptysis),
Jaundice, hepatomegaly

Investigations

Basic lab investigations

Hgb, WBC & differential, platelet count, urinalysis, blood group and Rh factor

Special investigations
a. Serum beta HCG or Urine HCG, in titer
b. Organ function tests
Liver function test
Renal function test
Thyroid function test (not routine)
c. Chest X-ray (for secondaries, cannon bole appearance)
d. Ultrasound (snow storm appearance in HFM)
e. Histological examination of specimen (expelled, evacuated or hysterectomy)

MANAGEMENT MODALITIES
1. General
Grant admission, prepare cross-matched blood
Correct hypo tension/shock, anemia, treat infection, PIH and hyperthyroidism.
2. Specific

Management of Hydatidiform Mole

Standard treatment:

a. Evacuate the uterus by suction curettage (in major OR ) and augment

by sharp curettage at the end of the procedure
b. An oxytocin infusion (10Iu/500ml 30 drops/min.) initiated after
moderate amount of tissue has been evacuated and continued for 1 to 2
hours after completion.
c. Patients who are Rh negative should receive Rh immune globulin at
the time of evacuation
d. Prophylaxis:

130
 Chemotherapy: - For patients who are unlikely to complete
post-evacuation follow-up and high risk to develop post molar
GTD (i.e)
HCG > 100,000 MIU/ml
Excessive uterine enlargement
Theca Lutein cysts > 6cm in diameter
Alternative Therapy

Primary hysterectomy is indicated for: -

Women who have completed their family
Complications such as bleeding and perforation.
Theca Lutein cysts are left untouched unless complicated
Post hysterectomy follow-up is the same as for post-suction
evacuation.

Follow-up
Every one-week until pregnancy test/HCG test is negative at least for three weeks
consecutively then ever month for three months then every three months for one year

At each visit
Perform a thorough clinical evaluation (History and Physical examination)
Determine HCG titer within 48 hours of evacuation followed by serial HCG in
titers on weekly basis until at least three negative results. Then monthly for 6
months to be followed by every two months for the next one year.
Avoid pregnancy, by prescribing oral contraceptive pills for one year.
Chest x-ray should be requested initially, then every 3 months for 1 year.
A patient with normal course could expect normal pregnancy outcome in the
future. However the couple should be counseled about increased risk of
subsequent molar gestation.

Management of Complications of HFM

Complications such as hemorrhage, uterine perforation and respiratory distress
syndrome, CVA require ICU care.

Management of GTDs other than HFM.

Criteria for diagnosis

a. Plateau or progressively increasing HCG values

131
 b. Histologic evidence of invasive mole, Choriocarcinoma or placental
site Trophoblastic tumor
c. Evidence of metastatic disease
d. Abnormal HCG level with evidence of metastasis following other
forms of pregnancy like ectopic.
Investigations
a. Hct, blood group & Rh factor, WBC, platelet, RFT, LFT
b. Immediate pretreatment HCG level
c. Metastatic survey
Chest X-ray
Ultrasound evaluation of the pelvis and abdomen
CT-scan of the lungs, brain, abdomen & pelvis, lumbar puncture
(Serum: CSF HCG usually > 60:1)

Categorization
A. Non Metastatic Disease
- No evidence of Disease out side uterus
B. Metastatic Disease
- Evidence of disease outside uterus

Metastatic disease can be: -

1. Good Prognosis Metastatic disease
a. Short duration (<4 months)
b. Low hCG level (<40,000 miu/ml of serum HCG)
c. No metastasis to the liver or brain
d. No antecedent term pregnancy
e. No prior chemotherapy
2. Poor Prognosis Metastatic Disease
a. Long duration (> 4 months since last pregnancy)
b. High pre-treatment HCG level (>40,000 miu/ml of serum HCG)
c. Liver or Brain metastasis
d. Antecedent term pregnancy
e. Prior chemotherapy

132
Management of non-metastatic Malignant GTD

Single agent chemotherapy is effective with:

A. Methotrexate 1 mg/kg IM or IV in days 1,3,5,7 with folenic acid 0.1mg/kg IV on

days 2, 4, 6, 8
Or
Dactinomycine 9-13 mg/kg IV/day for five days

1. Repeat the course every 14 days until remission is

achieved (3 consecutive normal weekly HCG)
2. Oral contraceptive pills for at least one year
B. Switch to alternative drug if: -
1. HCG titer rises (10 fold or more)
2. HCG titer plateaus at an elevated level ( 10%)
3. New metastasis appears

C. Laboratory work-up
Take HCG titers weekly until remission
Do not begin or continue course of chemotherapy if
a. White blood count< 3000/microliter
b. Granulocytes < 1500/microliter
c. Platelets < 100,000/microliter
d. BUN, AST, ALT and bilirulin are significantly elevated.
e. Sever stomatitis or other severe gastrointestinal symptoms
f. Febrile course
D. Follow up
1. HCG titer weekly until 3 consecutive negative titers, then monthly for 12
months.
2. Physical examination including pelvic examination and chest x-ray monthly
until remission, at 3 month intervals for 1 year
3. Continue contraception for a minimum of 1 year.

133
Management of low risk (good prognosis Metastatic GTD)
- Patients are expected to respond satisfactorily to single agent chemotherapy
Management of high risk (Poor prognosis metastatic GTD.)
1. Combination chemotherapy is the first line treatment in this group of patients.
Combination (MAC) chemotherapy
1. Given in 5 day course
2. Repeat cycles with minimum interval of 10-14 days, as toxicity allows.
3. Oral contraceptive agents to postpone pregnancy

Methotrexate, 10-15 mg/day IV or IM

And
D-Actinomycin 10 12 microgram/kg/day IV
And
Chlorambucil, 8-10mg/day orally, or cyclophosphamide, 3-5mg/kg day IV

Continue chemotherapy for 3 cycles after remission.

Laboratory investigations and follow-up is the same as out
lined in section C&D. Continue contraception for minimum of
2 years after remission.
Whole-brain irradiation to 3000 rads or whole liver irradiation
to 2000 rads (or both) In 10 fractions with chemotherapy.
Switch to alternative combination drug regimens (EMA/CO regimen) if
a. HCG titer rises
b. HCG titer plateaus after 2 courses of MAC
c. Failure to achieve normal titer after 2 to 5 courses of MAC
d. Increasing metastatic disease is evident.

In resistant cases, adjunctive measures along with chemotherapy may include:

a. Hysterectomy
b. Resection of metastatic tumors
c. Irradiation of unresectable lesions.
Common complications such as infections, renal failure, hemorrhage and marrow
depression should be treated accordingly.

134
Management of PSTT
a. Hysterectomy- for non-metastatic disease.
b. Combination chemotherapy for metastatic disease (EMA or EMA/CO)
Pregnancy after treatment of GTDs
The following points should be considered in planning pregnancy and conception
after GTDs
1. Counseling about the increased risk of molar gestation.
2. Ultra sound at 6-8 weeks of gestation
3. Histology examination of placental tissue after delivery.
4. hCG level determination 6-8weeks after delivery.

A. EMA/CO Chemotherapy regimen

Course A Drug Dose

Day 1 Etoposide 100mg/m IV infusion over 30
Methotrixate 100mg/m IV bolus
200mg.m IV infusion over 12 hours
Dactinomycin 500Hg IV bolus
Day 2 Etoposisde 100mg/m IV infusion over 30
Dactinomycin 500 mg IV bolus
Folinic Acid 15 mg Im, po every 6 hoursx4 doses
Begin 12 hours after methotrixate infusion
compeleted.
Course B
Day 8 Vincristine 1.0mg/m2 IV bolus
Cycloposphamide 600mg/m2 IV infusion
Day 15 Recycle course A
This is continued until remission is achieved & for 3 more cycles.

B. CHAMOMA regimen
Less effective than the above mentioned regimens.
It consists of Methotrexate, dactinomycine, cyclophosphamide,
doxurubicin, melphalan, hydroxurea & vincristine.

135
Management of High-risk sites of Metastatic GTD
a. CNS metastasis EMA/CO + Surgery & Radiotherapy
b. Liver metastasis EMA/CO + Radiotherapy
c. GI metastasis EMA/CO + Surgery
d. Renal metastasis EMA/CO + Surgery & Radio-therapy

Drug Resistant GTDs

In GTDs resistant to a particular combination therapy, the previous drug(s) used
should be revised to identify potentially active drug(s) which have/has not been
used.
Surgical extirpation of drug resistant foci of disease must be considered in-
patients with limited metastatic disease.
If the patient fails to respond to MAC regimen she may be tried on EMA/CO or
CHAMOMA regimen and vice-versa.
If the patient fails to respond to EMA/CO there are many other suggested regimes
among which are:
1. PVB (Cisplatin, Vincristin & Bleomycin)
2. EMA/EP (Etoposide, Methotrexate, Dactinomycin Etoposid,
Cisplatin)
3. EP (Etoposide, Cisplatin)
But there is no general agreement as to which one is best.
Remission: - 3 negative hCG values over 14 days.
Recurrence: - Re-elevation of hCG or appearance of new metastases after remission with
out intervening pregnancy.

136
 THE MANAGEMENT OF INFERTILE COUPLE

Infertility is a common problem affecting 10-15% of couples worldwide. Infertility is

believed to be more common in the developing countries due to the high prevalence of
RTI (STI, Post abortal and postpartum infections and genital Tb)
Eighty percent of couples attempting pregnancy achieve conception within one year with
regular intercourse of reasonable frequency, and additional ten- percent achieve by the
end of the second year.
The success rate for the treatment of infertility declines with length of infertility and
increasing age. Hence adequate investigation and treatment, if indicated, should not be
postponed. The investigation should always involve both partners.
The sequence in which infertility tests should be performed may be determined by
individual history and physical findings, which may suggest to look at one or another
factor first.
The global relative prevalence of the etiologies of infertility is as follows:
Male factor only 25-40%
Female factor only 40-55%
Both 10%
Unexplained 10%
CRITERIA FOR INVESTIGATION
When couples of reproductive age group fail to conceive after one year of normal sexual
practice without contraception.
DIAGNOSTIC SURVEY
A. Joint interview with husband and wife- (ideal)
B. Separate/ private consultations and physical examination paying attention to
the following points: -

137
Assessment of the male partner
1. History
a. History of previous fertility from the same or different partner,
duration of infertility.
b. Previous tests and therapy done for infertility.
c. Medical: General medical history including STDs, epididymitis,
mumps orchitis, any history of scrotal swellings chronic diseases,
drugs, recent febrile illness
d. Surgical: Herniorrhaphy: injury to testes, other surgery in genital tract
or orchidopexy
e. Occupational: Exposure to chemicals, radiation or extreme thermal
changes, and physical nature of occupation, vacations and work habits.

f. Sexual history: Onset of puberty, coital habits, ejaculation, libido, and

potency.
2. Physical Examination
General exam:
Status of general health,
Degree of androgenecity.
Reproductive system:
Position of urethral opening,
Testicular size (exclude epididymis-Normal >10cc up to 3.6-5.5),
Testicular and epididymal consistency,
Presence or absence of vas deferens; prostate size and consistency (on
rectal examination),
Careful examination for varicocele-performed in upright position
(Valsalva maneuver may be applied).
3. Investigations:
Basic
Hematology (Hgb, WBC with differential, ESR)
Urine analysis
VDRL
FBS

138
 Specific
Semen analysis: - Specimen taken after 2-3 days of abstinence. See Table I.
Special tests performed based on history, physical examination and Seminal fluid
analysis findings:

Sperm mucus penetration test

Sperm antibody testing
Karyotyping
Endocrine investigations (FSH, LH, testosterone, prolactin)
Imaging: X-ray of sella or CT scan,
Vasography, Scrotal U/S, doppler studies and Thermography.
Testicular biopsy
Table 1. Normal parameters for Semen analysis

Volume > 2 ml.

Concentration > 20 million
Total Sperm count > 50 million
Motility > 50% progressively motile
Morphology > 50 % normal forms
Inflammatory < 1 million cells/ml
Cells
PH 7.2 7.8
Fructose 140-280mg/100ml
Antibodies < 20% sperm binding to
bead
(Immunobead test)

139
Assessment of the female partner

Female factors: of infertility are classified as:

Ovulatory factor- 30 -40
Tubal/ peritoneal factor 30-40
Cervical factor- <5%
Uterine factor < 1%

History
Duration of infertility
Previous tests and therapy done for infertility
Fertility in previous marriages of self or spouses.
Number of pregnancies and abortions;
o Length of time required initiating each pregnancy
o Complications during any of the pregnancies
o Duration of lactation.

Contraceptive use, method and duration; detailed menstrual history; history of

STDs
General medical history including chronic and hereditary diseases. (Tuberculosis)
Abdominal, pelvic, and others
Sexual history: Libido, frequency of intercourse and post-coital practices.
Psychosomatic evaluation: General and with regard to the problem of infertility.

Physical Examination
General: Systematic and careful examination of the whole body with special attention
given

Habitus, fat and hair distribution, acne and other signs of endocrine disorders.
Reproductive system:

State of hymen, vaginal septum or other developmental errors,

Abnormal vaginal discharge,
Cervical stenosis, polyps,

140
 Uterine size, position and mobility;
Adnexal tenderness, indurations or mass, tumors,

Evidence of endometriosis or signs of acute or chronic PID.

III. Investigations: Basic
Hematology (Hgb, WBC with differential, ESR)
Urine analysis
VDRL
FBS
Vaginal smear

1. Ovulatory factor: -

History Regular menstruation with premenstrual symptoms

Clinical/ Lab investigations: Diagnosis of ovulation: -
Basal body temperature: Daily (oral/vagina/rectal) record of basal body
temperature early in the morning
0.5 to 10F rise over base line 97-980F at the
Ovulation & maintains high till next menses.
Cervical mucus test for ferning and Spinnebarkiet(stretchability)
Serum progesterone in late secretary phase More than 3 ng/ml
Luitenising hormone: serial determination is needed since ovulation occurs
34-36
Hrs. after start of LH surge and 10-12 hrs after pick value.
Not cost effective, as it require serial estimation
Ultra Sonography (Trans vaginal/Trans Abdominal) monitoring
Folliclular development can be followed until ovulation using USG
serially from 9th port menses day, until the day the follicle ruptures
(Ovulation is diagnosed by decrease in size of follicles, irregularity and
fluid in cell de-.
It is reliable and non invasive and it can also be used to measure the
thickness of endometrium at the same time.
Endometrial Biopsy: in late secretary phase (21-24th day of menses)
Secretory endometrium if ovulation has occurred
Lag in endometrial development if luteal phase defect
TB endometritis if histopathological examination

141
 Vaginal cytology: - (Lat-wall of vagina)
It is less invasive than Endometrial biopsy
However requires serial cytology to date the day of ovulation & so
could not be called cost effective.
The Presence of envelope cells or large sq cells more than cornfield
cells indicates progestogenic phase.

2.Tubal/peritoneal factor: -
Hysterosalpigography: done on 6-11th days postmenstrual after ruling out acute
infection
It gives good information about tubal block or hydrosalpinx
Including anatomical detail of uterus or any anomaly.
It is invasive, but cost effective and informative
Laparascopy:
Diagnosis of peritubal adhesions, endometriosis, hydrosalpinx etc.
Dye test for tubal patency
Hysterescopy: Visualization of the tubal ostium

3. Cervical factor:
Postcoital test
Sperm penetration assay
Hamster zona cell penetration test

4.Uterine Factor: The Uterus is assessed for anatomical defects and any endometrial
pathology responsible for Infertility
Hysterosalpingography:
Diagnostic laparoscopy /Hysteroscopy to
Diagnose anatomical abnormalities like septate,unicornuate, bicornuate uterus
Diagnose Ashermans syndrom/intrauterine synechea
Ultra sonography: pelvic /uterine mass detection
Endometrial Biopsy: for endometrial pathologies like TB

TREATMENT REGIMENS
A. MALE
1. Normal semen analysis - Two specimens at intervals of at least 3 weeks apart.

No medical treatment required counseling suffice.

142
2. General empirical treatment for conditions like oligospermia, & asthenozospermia
a. Advice adequate rest
b. Abstinence from alcohol, smoking, chat chewing
c. Avoid hot baths, tight under wear.
d. Correct obesity, infection, and immune factors.
3. Surgical corrections of causes like varicocele, hypospadias and epispadias
4. Idiopathic- abnormal semen
- Empirical treatment with
a. Clomid 50 mg/d- 3-6 months
b. Testosterone (proviron, testoviron depot) 25-50mg qid p.o for 70 days
200-250mg every 10-14 days IM. For 2 months
Thyroxin 0.2mg/day till good result
c. Bromocriptin
1.25mg x2/1wk, then gradual increase up to 20mgx2 and to continue
till good result is obtained
d. AID, AIH, ART, ICSI (These techniques are not currently practiced
here).
B. Female
Anovulatory cycle: induce ovulation.
1 Clomid (Clomiphene Citrate)
Stage Month
1 1 50mg/d 5days 1st cycle, day 5-9th of the cycle if no ovulation,
2 2 100mg/d- 5days 2nd cycle, day 5-9th of the cycle if no ovulation,
3 3 150mg/d 5 days 3rd cycle day 5-9th of the cycle if no ovulation
4 4 200mg/d 5 days 4th cycle day 5-9th of the cycle if no ovulation
5 6-8 No treatment
6 9 Clomiphene 100mg/day + HCG 5000 iu
7 days after
7 10 Clomiphene 150 mg doses+ HCG 5000 iu
Use 7 days after
2. Bromocriptin

143
 1.25 mg x 2 / 1st wk test
2.5 mg x 2 for one month
No response increase up to 20mg x 2 till pregnancy
3. Thyroxin 0.2mg/d till response if evidence of hypothyroidism
4. Dexamethesone 0.5 0.75mg/day for 6-8 months or
methyl prednisolone 4mg/ day 6-8 months
5. Combination treatment
a. Clomid as 1 plus
- Progynon depot 20mg/i.m
10mg/i.m day on 14th day
b. Clomid as 1 plus
- Dexamethasone 0.5-0.75mg/day - 2-3 months or
Methyl Prednisolone 4mg/day 2-3 months
c. Clomid as 1 plus
- Bromocriptine dose as mentioned in 2
3. Abnormal PCT
3.1 Treat for infection
Erythromycin, tetracycline, bactrim, vibramycin or anti TB drugs as
indicated.
3.2. Treat immune problems
- Condom occlusion therapy 6-9 months
- Immune suppression
- Suppression of spermatogenesis
- Intrauterine insemination (AID, AIH)
4. Genital abnormality surgical correction
5. ART (IVF, GIFT, ZIFT, TET, POST)
6. Donor oocyte
7. Surrogating
8. Adoption

144
 THE MANAGEMENT OF SEXUAL ASSAULT

Sexual assault may be defined as any sexual act performed on another person without
consent. Although legal definitions vary, sexual assault (rape) is often further stratified to
include acquaintance rape, date rape, statutory rape, child sexual abuse, and incest based
on the age of the victim and relationship to the abuser.

Sexual assault occurs in all age, racial, and socio-economic groups. The very young, the
mentally and physically handicapped and the very old are particularly susceptible.

While the actual incidence of sexual assault is not known, it appears to be rising almost
all over the world. It causes serious impact on the victims health such as unplanned
pregnancy, STDs, physical trauma and a spectrum of psychological disorders.

Physicians evaluating the victim of sexual assault have a number of responsibilities, both
medical and legal, and should be aware of the law of the country they work in relation to
the situation. Main areas of concern are medical treatment, prevention of STI and
pregnancy, evidence collection and rehabilitation.

CLINICAL EVALUATION
A. Initial Evaluation
1. Obtain informed consent from the victim or relatives
2. Obtain an accurate obstetric and gynecologic history including: -
The details of the sexual act(s) performed.
Previous obstetric and gynecologic conditions; particularly infections, pregnancy,
use of contraception, LNMP.
Time of last consensual intercourse.
3. Perform a meticulous physical examination and collect evidence.
a. Careful examination of the entire body and photographs or drawings of the
injured area(s) is made.
b. Inspection of the external genitalia and perineum should be made with
good illumination.
c. Pelvic examination to assess the status of the reproductive organs as
indicated.
d. Search for bruises, abrasions or lacerations elsewhere on the body.
e. Collect samples from the cervix and vagina
4. Perform pertinent vaginal laboratory investigations (baseline).
a. Samples for motile spermatozoa, acid phosphatase,

145
 Wet smear for T.vaginalis, grams stain N. Gonorrhea and chlamydia
testing.
b. Culture specimens from the cervix, mouth and rectum when indicated
c. Serologic test for syphilis.
d. Hepatitis B surface antigen.
e. Serology for HIV Infection (after counseling)
f. Pregnancy test (reproductive age group)
5. Assess the psychological status and act accordingly Counseling and referral to
Psychiatrist as needed
B. Follow up evaluation two weeks and 12 weeks later
Screen for STI and treat
Screen for pregnancy and manage
Asses emotional status
Repeat serum test for HIV at 3 and 6 months

MANAGEMENT
1.Appropriate medical or surgical treatment for acute injury.
Baths in plain or salted warm water for superficial abrasions.
Surgical suturing for larger and actively bleeding laceration (general
anesthesia may be required)
Analgesics for pain
2. Prophylaxis for STDs.
Empiric antimicrobial therapy for chlamydial, gonococcal and trichomonas
infection.
Ceftriaxone 250 mg im in single dose, plus
Metronidazole 2gm orally in single dose, plus
Doxycycline 100mg orally two times a day for 7 days.
Prophylactic antiretroviral treatment

Use Erythromycin in the place of Doxycyclline for pediatric cases and in those allergic
to Tetracyclline
NB. Alternative treatments may be given.
3. Pregnancy prevention
Emergency contraception
Options:
a. High dose (50 mcg) estrogen Oral Contraceptive Pills (OCP),
e.g. Ovral Dose: 2-tabs12 hours apart (total 4 tabs)
b. Low dose (30mcg) estrogen Oral Contraceptive Pills

146
 e.g. Nordette Dose 4 tabs 12 hours apart (total 8 tabs)
c. IUD (Copper IUDs are preferable) insertion up to 5 days post
exposure
4. Hepatitis B Prophylaxis (vaccine if indicated)
5. TAT (if indicated)
6. Provide appropriate counseling and psychological support.

IV. LEGAL CONCERNS OF SEXUAL ASSAULT

Record events accurately
Document injury with diagrams
Collect sample (pubic hair, fingernail scraping, vaginal secretion,
saliva, blood-stained clothing) to be sent for forensic examination
when ever possible.
Report to authorities as required.
Assure orderly and unbroken chain of evidence.
Medico legal certificate as indicated

147
 CHEMOTHERAPY FOR OVARIAN TUMOR

Use of Chemotherapy in any malignancy

Should be restricted to patients with histologic diagnosis i.e. should not be used as
diagnostic trial.
Shouldnt be used unless there is objective benefit
Should consider
o Natural history of the particular malignancy
o Patient
o Likelihood of achieving a beneficial response
o Pt's social and financial situations
Should be used only when facility to monitor and treat toxicity is available

Differential sensitivity to chemotherapeutic agents

Any antineoplastic should be more toxic to malignant cells then normal cells but due to
their mechanism of action toxicity to normal cells is inevitable & differential effect is
more of quantitative then qualitative.

1) Therapeutic index Ratio of a dose at which therapeutic effect and toxicity occur
(Usually narrow)

2) Cell cycle specific Vs non-specific

3) Log kill hypothesis: - agents work by 1st order kinetics (kill a constant faction of cells
rather than constant member)

4) Drug resistance and tumor cell heterogeneity

5) Dose intensity phenomenon.

Principles of combination chemotherapy

Is the standard of management for ovarian tumors.

Important factors in designing drug combinations

1. Drug must be active as single agent to the tumor

2. Should have different mechanism of action to decrease resistance.

148
 3. Should be at least additive & preferentially synergistic.

4. Should have different spectrum of toxicity to get maximum cell kill at full dose.

5. Should be administered intermittently so that cell kill enhanced & prolonged

immune suppression is minimized.

Dose Adjustments

Is tailoring the Rx to the patient using sliding scale technique:

Bone morrow response

1. WBC counts Dosage system

>4000/mm3 100% of all drugs

3999-3000/mm3 100% of non myelotoxic and 50% of each

myelotoxic agents

2999-2000/mm3 100% of non myelotoxic and 25% of each

myelotoxic agents

1999-1000/mm3 50% of non myelotoxic and 25% of each

myelotoxic agents

999-0/ mm3 No drug till recovery

2. Platelet count Dosage system

> 100,000/ mm3 100% of all drugs

50,000-100,000/ mm3 100% of non myelotoxic and 50% of

myelotoxic

<50,000/mm No drug till recovery of count

149
Liver

Bil AST (Doxorubicin) (Vinblastin/Vincristin/Etoposide)

<1.5 <60 100% 100%

1.5-3 60-180 50% 50%

3.1-5.0 >180 25% Omit

5.0 - Omit Omit

Paclitaxel

AST >2x normal <135mg/m2

Bil 1.6-3.0 < 75 mg/m2

Bil > 3.1 50 mg/m2

Renal; similarly can be scaled by creatinine clearance.

Antineoplastic Drugs

1. Alkylating agents :Cyclophosphamide, melphalan, chlorambucil,TSPA,Ifosphamide

2. Anti metabolites MTX, 5-FU, 6-mercaptopurine

3. Anti tumor antibiotics Dactinomycin , Bleomycin, adriamycin , Mitomycin-C,

Mithramycin

4. Plant alkaloids;Vincristine, Vinblastine, Paclitaxel, taxotere, epipodophyllotoxin

5. Hormones;MPA,hydroxy progesterone caproate, Megestrol acetate

6. Others (Miscellaneous)- hydroxyurea, Cisplatin, carboplatin, hexamethylmelamine,

decarbazine. Etc.

150
Indication for use of chemotherapy in the management of ovarian tumor.

1. Post cytoreductive surgery for metastatic ovarian malignancy

2. As primary Rx of advanced ovarian malignancy wilt a plan of interval

cytoreductive surgery

3. Salvage treatment of recurrence

Chemotherapy for Epithelial Ovarian tumor

Single agent (Mono-chemotherapy)

For pts with metastatic epithelial ovarian tumor, use generally reserved for
patients whose overall physical condition precludes the use of more toxic therapy.

Could be used in patients with stage 1a and 1b grade 2 and 3 and stage 1c
patients.
Regimens

1. Cyclophosphamide 500mg/m2 IV for 3 day-repeat Q3-4 weeks

2. Melphalan 1mg/kg Iv for 5 days or 0.2mg/kg po for 5 days and repeat in 4 weeks.

3. Hexamethylmelamine 150mg/m2 po daily till complete remission.

4. Cisplatin 50-100mg/m2 in an infusion solution after hydration.

Cisplatin or carboplatin for 3-4 cycles, melphalan for 4-6 cycles.

Poly Chemotherapy

Is the standard of Rx of metstatic epithelial ovarian tumor, single agent used only when
use of poly-chemotherapy is precluded.

151
Regimens

Regimen Interval

PT Cisplatin 75-100mg/m2 3 weeks

Taxol 175-210mg/m2

CT Carboplatin 300mg/m2 3-4 wks

Taxol 135-175mg/m2

PC Cisplatin 75-100mg/m2 3 wks

Cyclophosphamide 650-1000mg/m2

CC Carboplatin 300mg/m2 4wks

Cyclophosphamide 600mg/m2

PAC Cisplatin 50mg/m2 3-4wks

Doxonibucin 50mg/m2

Cyclophosphamide 500mg/m2

CHAP Cyclophosphamide 350mg/m2 1V

Day 1 and 8

Hexamethy1melamine 150mg/m2 po

Day 1-14

Doxorubucin 20mg/m2 iv day 1and8

Cisplatine 60mg/m2 IV day 1

The best regimen recommended is PT

Always determine CBC, Platelate count, RFT, LFT and electrolytes before chemotherapy
cycle and titrate the dose with sliding scale.

152
Treatment assessment

1. Tumor markers- Carcinoembryomic Antigen and CA- 125

2. Radiologic assessments

3. FNA if mass detected.

4. Second look laparotomy/laparoscopy- Value doubted in absence of evidence of

recurrence.

Treatment of recurrence

1. Secondary cytoreduction

2. 2nd line chemotherapy

a. High dose cisplatin (100-150 mg/m2) IV with the other combinations

previously not used

b. Intraperitoneal chemotherapy csplatin is the most effective but various

combinations could be used

3. Whole abdominal irradiation

4. Experimental treatments

Chemotherapy for Germ cell tumor of ovary

BEP- Regimens

Bleomycin - 15 units/m2 / wk x5 then on day 1 of course 4

Etoposide - 100 mg/m2 / d x 5 days every 3 wk
Cisplatin - 20-mg/m2/ day x 5 days or 100mg/m2 /d x 1 day every 3 wk
VBP Regimens

Vinblastine - 0.15 mg /kg day 1 and 2 every 3 wk

Bleomycin - 15 units /m2/ wk x5 then on day 1 of course 4
Cisplatin - 100 mg/m2 on day 1 every 3 wk
VAC Regimens

Vincristine 1.5 mg /m2 on day 1 every 4 wk

153
 Actinomycin - 0.5 mg / day x 5 days every 4 wk
Cyclophosphamide150mg/m2/day x 5 days every 4 wk

Chemotherapy for recurrent germ cell tumors

POMB/ACE
POMB

Days 1 - Vincristine 1 mg/ m2 Iv, Methotrexate 300mg/m2 as a 12 hr infusion

Day 2 - Bleomycin 15 mg as 24 hr infusion, folenic acid rescue started at 24 hr after start

of MTX
Day 3 - Bleomycin infusion 15 mg by 24 hr infusion
Day 4 Cis-platin 120 mg /m2 as a 12 hr infusion given together with Hydration and 3
gm Mg S04 supplementation

ACE
Day 1-5 Etoposide (Vp 16-213) 100 mg /m2 day 1-5
Day 3,4,5 Dactinomycine 0.5 mg IV, day 3,4,5
Day 5 Cyclophosphamide 500 mg/m2 IV day 5

Administration of Chemotherapy
1. Admission (Chemotherapy should be given on in patient basis)
2. Pre chemotherapy patient assessment and lab results should be available; titration of
dose made according to the findings no more than 5 days old
3. Clear order should be written in the order sheet, which should include
Each of the chemotherapeutic agents to be used, amount and duration,
(use generic name)
The regimens to avoid complications of chemotherapy
Hydration regimen
Anti emesis
Carrier solution of the chemotherapeutic agents

154
Guidelines for Hydration
The following anti-neoplastic drugs need a standard hydration

1. Cis-platin:
1000- 1500 ml of normal saline or ringer lactate solution given at a rate of
300-500 ml/hr for 2-4 hrs until urine out put is greater than 100 ml/hr. Can use Foley
catheter for monitoring urine out put.
Hydration is followed by 12.5 g of mannitol in 50 ml of saline infusion
When urine out put is satisfactory start Cis-platin infusion in normal saline and
finish it in 1-1.5 hr period
Post Cis-platin IV fluid rate 150-200 mg/hr for the next 6 hrs and can
discontinue iv fluid if pt stable after 6hrs

2. Cyclophosphamide: Pre hydration and post hydration regimen mandatory when dose
used is > 1500 mg /m2

N/S 1000 ml over 2-4 hrs pre- cyclophophamide

Administer Mesna IV (20-40 % of cyclophosphamide dose 15 minutes before
cyclophosphamide and at 4 and 8 hrs after cyclophosphamide
Administer cyclophosphamide
Post cyclophophamide give N/S 1000 ml over 2-4 hrs and Mesna as indicated
above

3. High dose MTX

Administer 5% D/W with 100 m.eq. Na HCO3 pre and post MTX. to keep urine
PH >7 for 48 hrs post MTX infusion
Initiate Leucovorine after 24 hrs as per infusion

4. Ifosfamid - As cyclophophamide

155
Guideline for antiemesis management

1. Acute emesis
Is the occurrences of emesis within the 1st 24 hrs of treatment
Determine the level of emetogenecity of the chemotherapeutic
agent to be used (table 1)
Define emetogenecity of the combination chemotherapy (table 2)
Treatment and prevention of emesis as in the algorithm and dose as
in table 4
Principles
All patents receiving serotonine antagonist should be treated
concomitantly with Dexamethasone
Serotonine antagonists Iv (Ondanestrone), the pre chemotherapy
dose given 30 min prior to the offending chemotherapy.
2. Delayed emesis

Is the occurrence of emesis after 24 hrs of chemotherapy

occur b/n 24/hr and 10 days
This occurs with regimens using Cis-platin, carboplatin, high dose
alkylating agents.
Treatment should began 8 hrs after the last dose of acute
prophylactic anti emetic and continue for at least four days
following platinum based and for 24-36 hrs after
cyclophosphamide and Doxurubicin.
Dose - Metoclopramid 0.5 mg/kg IV/PO Qid for 2-4 days then
every 4 hrs PRN
Dexamethasone 8mg IV/ PO Bid x 2 days then 4 mg x 2 days
Diphenhydraimine 50 mg PO every 4 hrs pin only restless and
acute dystonic reaction
(Or as in table 4)
3. Break through Emesis
Patient request for antiemesis or Vomit > 2 times give
Metoclopramid 1-2 mg/kg Iv but minimum of 3-4 hrs
between doses.

156
 Diphenhydraimine- 50 mg Iv every 30 min only for
restlessness & acute dystonic reaction
4. Anticipatory emesis

Patients who suffered form nausea and vomiting during their previous
chemotherapy exercise may suffer from anticipatory emesis.
Use Lorazepam or one of Benzodiazepines

Guide line for tumor lysis prophylaxis

Administer 5% D/W and N/S with 100mg NaHco3 at 150ml/hr as a continuous
infusion through out chemotherapy
Consider Allupurinol 300mg PO every day.

157
 Cesarean section

The delivery of the fetus placenta and membranes through an incision on the abdominal
and uterine walls is known as cesarean section.
Cesarean section is an operative delivery used in situations when safe vaginal delivery
either is not feasible or would impose undue risks to the mother or the fetus. Cesarean
section can be Elective when the procedure is planned. It can as well be Emergency when
there is an emergency indication that necessitates the immediate delivery of the fetus.

Pre operative preparation

Pre operative preparation for elective cesarean section: includes the following basic
preparations and any other necessary preparations as indicated by the presence of other
medical problems
Time: Elective cesarean section should preferably start at eight- nine in the
morning

Lab investigations
o Hct. or Hgb bl group and Rh
o Urine analysis
o Cross match blood as necessary 2 or more units
Get written informed consent
Keep the mother NPO after mid night
Start IV fluid in the morning
Administer Prophylactic antibiotics
Transfer the mother to the operation theater with stretcher in lateral position
Instruct the mother to void just before the procedure or catheterize
Start the Cesarean section at 8:30am. In the morning

Preoperative preparation for emergency cesarean section:

Lab investigations
o Hct. or Hgb bl group and Rh
o Urine analysis
o Cross match blood as necessary 2 or more units
Get written informed consent
Administer a teaspoonful of antacid solution
Open IV line with cannula
Catheterize

158
 Administer Prophylactic antibiotics or start treatment as needed
Transfer the mother to the operation theatre in the appropriate position
Make sure:
The anesthesia team, the necessary drugs and equipments,The neonatal resuscitation set
and personnel are in place

Anesthesia can be:

Regional (Spinal): administered while the surgeon and scrub nurse are preparing for
surgery
General: Administered after the surgeon and scrub nurse are ready, the abdomen
(operation site) is cleaned and draped.

Procedure
Cesarean section can be: Classical
Lower segment transverse,
Lower segment vertical based on the incision made on the uterus

Abdominal incision:
Pfannensteil incision: Strong op site, less risk of dehiscence and hernia
Sub Umbilical midline incision: Fast, less hemorrhagic and can easily be extended
if need arises
Incise the skin and subcutaneous tissue
Make a small incision over the fascia with a scalpel
Incise the whole length of the fascia with scissors
Dissect the rectus and pyramidalis muscles by sharp instrument and then with
blunt dissection
Elevate the peritoneum at the upper edge of the incision by holding it with two
artery forceps about 2 cms. apart
Palpate the tent of peritoneum to check if omentum or bowel is not grasped
If grasped release the artery forces and grasp again
Incise between the two artery forceps with scalpel to open the peritoneal cavity
Check if there is adhesion of the peritoneum or dense infiltration by inserting a
finger and palpating up and down the peritoneal opening
Extend the peritoneal opening with scissors up wards up to the upper border of the
incision and downward up to the reflection of the bladder checking for any
adhesion.
Correct the uterus if dextro-rotated

159
 Insert moistened packs on each side of the uterus
Insert a bladder retractor

Lower segment transverse cesarean section:

Grasp the peritoneal flap at the site of the reflection with forceps and incise with
scissors
Dissect the peritoneal flap at the reflection site be inserting the scissors between
the serosa and myometrium.
Open up your instrument to dissect the peritoneum and then cut moving to the left
and right side of the uterus (The assistant moves the bladder retractor to the side
you are moving your scissors)
Push the peritoneum downwards with gauze on a holder or using your fingers
Incise transversely over the exposed uterine lower segment for about 2 cm with a
scalpel
NB your incision should be just enough to cut through the myometrium and not
reach the fetal part neither too shallow to peel the myometrium
Extend the incision bluntly with your index fingers of the two hands laterlly and
upwards
Rupture the amniotic membrane if encountered
Insert your right hand between the symphysis pubis and the presenting part and
elevate the vertex gently through the incision assisted by gentle abdominal
pressure
Wipe the nares and mouth once the head is delivered
Deliver similarly if multiple fetuses
Administer oxytocics to manage the third stage actively
Deliver the rest of the body
Clamp the cord at two sites and cut in between
Hand over the neonate to the midwife for immediate newborn care
Administer uterotonics
Deliver the placenta by CCT or manual removal
Clean the uterine cavity with pack to ensure completeness of the placenta and
membranes
Clamp the edges of the uterine incision and any briskly bleeding sites with green
armitage or ring forceps
Lift the uterus out of the abdominal cavity and cover the fundus with moist pack

160
 Close the uterine incision with two layers of continuous inverting stitches starting
from the edge the first bite just behind the edge use Chromic 1 or 0 catgut or
vicryl
Close the peritoneum with chromic 2-0 catgut
Make sure hemostasis is secured and uterus is well contracted
Replace back the uterus into the abdominal cavity
Dry the abdominal cavity with gauze pack
Close the Fascia with continuous vicryl no 2
Approximate the subcutaneous layer with chromic 2-0 catgut
Close the skin with Continuous subcuticular stich or interrupted silk as needed

Classical Cesarean section:

Indication: inaccessible lower segment because of tumors or adhesion
Procedure:
Abdominal incision should be sub-umblical midline
Open the abdomen as above
Make vertical incision on the body of the uterus
Deliver the fetus/fetuses breech/ vertex
Manage the third stage actively
Close the uterine wall in three layers
Close the abdomen in layers as indicated above

Postoperative follow-up:
Immediate:
Check vital signs on arrival to the ward and every 30 min then after Until mother
is fully awake
Check for vaginal bleeding
Late:
check vital signs every 6 hours
Start sips followed by fluid after 12/24 hrs after ascertaining that the bowel
sounds are active

Discontinue IV fluids when mother has started fluid diet if no other IV medication
is needed
Ambulate
Look for evidences of PPH, pulmonary infection, UTI, and wound infection
Initiate breast-feeding as soon as the mother is awake

161
 Open the wound site and remove stitches on the sixth day
Discharge when vital signs are with in normal range, mother has started regular
feeding, breast-feeding is initiated and there is no evidence of wound infection

162
 MANAGEMENT PROTOCOL ON FORCEPS DELIVERIES

Forceps
Obstetric forceps is a pair of instruments, which mostly assists to effect delivery of the
fetus.

Function of Forceps:

Traction: - pull of 18 kg in primes & 13 kg in multi.

Rotation: Only by Keilland Forceps.
Protector Head between two blades in cephalic application (Premature baby)
As vectis single blade used during CS, to effect delivery of head

Type: - Long curved forceps Simpsons forceps (37 cm)

Short curved forceps Wrigleys forceps (17-25cms)
Special forceps (Long & Rotator) like Keillands forceps and Pipers
forceps.
Forceps operations -
Acceptable forceps opertions with minimum trauma to the mother and fetus are
Low forceps BPD is below O station (90%)
Outlet forceps It is a type of low forceps
application when head is at perineum and visible at
introitus between contractions.
High mid & high forceps have been replaced by C.S,

Indications of Forceps operation:

i) Delay in 2nd stage
ii) To shorten the 2nd stage in cases with
Maternal Distress
Pre Eclampsia, Eclampsia
Cardiac or pulmonary diseases
Glaucoma, CNS aneurysim etc
iii) Fetal indication: -
Fetal distress in 2nd stage
Low Birth weight baby
After coming head of Breach

163
Prerequisites for forceps operation
Correct presentation & position (vertex, Face-mento Anterior,
After-coming head in breech)
Cervix should be fully dilated
Membranes must be ruptured
Head must be engaged station plus 2 and below
NO CPD
Bladder should be empty

Preliminary preparations for Forces operation

Anesthesia Regional or local
Catheterization
Internal pelvic Examination
- To rule out CPD
- To ascertain presentation, position and station
Episiotomy Deep medio-lateral for long forceps
Steps in forceps delivery
Hold a complete (locked) forceps in front of the perineum to orient and
identify the right and left blades. The right is the one on the right side of
the mother and the left on the left
Disassemble the forceps and place it on the tray
First apply the left blade: Hold the handle of the left blade with your left
hand freely and apply it to the left side of the mother guided by the two
fingers of the right hand.
Apply the right blade: Hold the handle by your right hand and place it to
the right side of the mother guided by the two fingers of the left hand.
Lock; the right is always below the left when locked
Locking should be very easy
If locking is difficult disarticulate and apply again after ascertaining the
absence of CPD, position and station.
Never apply undue force to lock
IF FORCEPS LOCKS EASILY DO THE THRE CHECKS
1. Plain of the shanks is as close to the Occiput as possible
2. Shanks are equidistant
3. Fenestra doesnt accommodate more than two fingers.
Traction:
Intermittently preferably synchronized with uterine contractions

164
 Traction should follow the line of Carus (Pelvic Curve)
Removal - Right first and left next

Difficulties in forceps operation

During Application -
Incompletely dilated cervix
Un rotated or unengaged head
During locking
Application with un rotated head
Compound presentation
Improper insertion of blades (too far in)
Failure to depress handle properly before locking
Difficult traction
Undiagnosed mal position (O.P.)
Faulty cephalic application
Wrong direction of pull
Mid pelvic contraction
Constriction ring
Slipping of blades: -

a. Faulty application
b. Blades should be equidistant from the &sinciput and occiput

Special Terminology with forceps operations: -

Prophylactic Forceps

Trial of forceps: -
i) A tentative attempt to deliver by Forceps in presence of
doubtful mid pelvic - contraction with prior preparation for C.S in
case the attempt fails.
ii) It is to be attempted in OR and by an expert obstetrician

Failed Forceps: - a) when a deliberate attempt to effect delivery by forceps

has failed, is called failed forceps, causes could be:

Failed Forceps is unindication for cesarean section

165
 Management Protocol on Ventouse Deliveries

VENTOUSE:
Ventouse is an instrument designed to effect vaginal delivery by creating
vacuum between its cup and fetal scalp, thus synonym is vacuum delivery.
Description of Instrument

Component: -
-Suction cups of 4-size s
(30,40,50 & 60 mm)
-Metal or soft silastic cup
-Vacuum pump/ Electrical vacuum pump
-Traction rod device with rubber pipe
Indications:
As an alternative to Forceps except in
Face presentation
After coming Head
Contraindications: Face presentation
Extreme Prematurity
Fetal coagulopathy

Advantages of Ventouse over Forceps: -

It can be used with advantage on un rotated or/and mal rotated OP

It can be applied through incompletely dilated CX
Does not occupy space in pelvic as Forceps
Lesser traction force (maxim 10kg)
Safely used for high head without CPD
Less traumatic to mother & foetus
Requires less technical skill

Disadvantages of Ventouse over Forceps: -

It is not an instrument for fetal distress where quick delivery is required
It is not safe for premature fetus
Cannot be used for face presentation or after coming head where forceps could be
used
Technical failure is more common with Ventouse as it is not simple as Forceps

166
 Prerequisite of ventouse delivery
No pelvic contraction of any degree
Engaged Vx presentation;
Cervix should be at least 8 cm dilated
Membrane should be ruptured
Empty bladder
Local infiltration of anesthesia & episiotomy
The instrument is to be assembled and vacuum to be tested prior to its
application

Steps of operation:
Cup application
Select proper size cup as per dilation of cervix
Place cup on fetal head near to occiput
Knob on cup should point to occiput (It will guide flexion of head & degree
of rotation).
Check for entrapment of maternal tissue and release before creating vacuum

Vacuum creation:
Rate 0.1 kg cm2 /minute
Maximum vacuum 0.8 kg/cm2
Time 10-12 minute
By hand pump or Electric pump
(Fast vacuum creation leads to improper creation of chignon & failure of operation)

Traction
Rt angle to cup
Synchronous with uterine contraction
Along axis of birth canal using one hand and other hands finger on cup to
guide traction, rotation & descent of the head
Time not to exceed 30 minute to effect delivery
If four successive pulls fail to advance the hand then abandon the operation
As soon as head is delivered vacuum to be released.
Complete the delivery in routine manner.

167
Complications: -

Maternal: - Trauma to soft tissue if Cx or vaginal wall is sucked into

cup.
Fetal: - i) Laceration of scalp
ii) Cepholahaematoma
iii) Subaponeurotic Haemorrhage
iv) Intracranial Haemorrhage

168
 MANAGEMENT PROTOCOL on DESTRUCTIVE OPERATION
A) Definition: - The destructive operations are done to reduce the bulk of the dead
fetus due to obstructed labor to facilitate the delivery through the birth canal.

B) Types: - (i) Craniotomy

(ii) Evisceration
(iii) Decapitation
(iv) Cleidotomy

Craniotomy: -

Definition- To perforate fatal skull to evacuate the contents followed by

extraction of the fetus
Instruments: - a) Oldhams perforator
c) Bu dins canula
d) Big Mayos scissor

Indication:
a) Cephalic presentation with obstructed labour and
dead fetus.
b) Hydrocephalous & obstructed labour
c) Interlocking head of Twin

Prerequisites: -
a) Cervix fully dilated
b) Dead Fetus
Contraindication: -
Severe contracted pelvis having true conjugate less than 7.5 cm as
Bimastoid diameter is 7.5 cm and it is uncompressible, thus baby can
not be delivered.
Ruptured uterus (Laparatomy needed)
Dead fetus without obstruction.
Doubtful fetal demise (Benefit of doubt goes to mother & fetus)

169
Procedure: -
Preliminaries: -
Start IV line with crystalloid and resucitate.
Consent of the patient/ parent.
Anesthesia as per individual need
Rule out severe degree of contracted pelvis (true conjugate 7.5 cm or
less)
Confirm position & presentation of the fetus
Aseptic & antiseptic care

b) Steps: -
Place two fingers per vaginum over one of the parietal bone (avoid
suture line)
If sutures are obscured due to caput then chose dependant part.

Sites-
vertex parietal bones either side of sagital
Suture
Face - Orbit/hard palate
Brow - Frontal bones
After coming head- Foramen magnum
Introduce perforator, with closed blade, under palmer aspect of
fingers protecting anterior vaginal wall & bladder at predetermined
site.
By rotating/screwing perforator is introduced
Assistant should fix and steady head per abdomen like first pelvic
grip
Perforator goes in up to shoulder of the instrument and
Handles are closed to open the blade about 2.5 cm apart
Handles are separated to close the blades and pulled out, to
Be trusted again up to previous level and rotatory movement inside
skull is made
Once drainage of the content is complete the perforator is
Brought out under cover of fingers in side the vagina
Alternatively sharp big mayos scissor also can be used for this
operation

170
 Brain matter is drained
Once head collapses sufficiently it is pulled down & out with help
of strong volselleum/sponge holding forceps or bone forceps
clamped at four quadrants.
Baby is extracted following head as it is done in forceps operation
Manage the third staghe actively.
Inspect the genital tract for trauma or rupture of uterus

Decapitation:
Decapitation is Severing of the fetal head following fetal demise with obstructed labor
and delivery is completed with delivery of trunk and decapitated head through birth
canal.
Instruments: -
a) Decapitation hook with Jardins knife
b) Embryotomy scissor
c) Hook with crochet
d) Giant volsellum
Indication: -
a) Neglected shoulder presentation with fetal death, when neck is
easily accessible
B) Inter locked head of twin
Prerequisite
Same as for craniotomy
STEPS
If hand not prolapsed bring down a hand
Tie ribbon on wrist and ask assistant to put on traction to make neck
accessible &fix
Keep two finger palmar surface downward on neck under which
instrument to be passed protecting ant vaginal wall and bladder
Introduce decapitation hook with knife under fingers already in vagina,
the knob pointing toward head.
Push hook above neck rotate it 900 to fix firmly against the neck
Change internal fingers site by placing now under the neck to guard
the tip of hook
Make upward & down ward movement till vertebral column is cut
(sudden loss of resistance felt)
Catch remaining soft tissue by some hook

171
 Cut remaining soft tissue by same hook & knife or use embryotomy
scissor
To remove the hook, push it upward above neck and rotate again back
900 & to take out under internal fingers
Deliver trunk first by pull on prolapsed arm
Then retrieve & deliver decapitated head by hooking finger in mouth
or by crochet, fixing it with lower jaw or by holding severed soft tissue
of neck with giant volsellum
Routine exploration of the utero vaginal canal to exclude rupture of the
uterus & trauma to birth canal

Note: - It can be done with help of Blond Heidler thimble and wires saw .

Evisceration: -

Evisceration is Removal of thoracic and or abdominal contents by piecemeal through an

opening in abdomen or thorax at most accessible site.
Instruments: Embryotony Scissor
Indications a) Neglected Shoulder presentation with dead foetus & neck not
Accessible
b) Fetal Malformation (Fetal Ascitis, Monsters, Huge Distended
Bladder & Hydronephrosis)

Cliedotomy:
Cliedotomy is reducing the bulk of the shoulder girdle of the dead fetus by cutting one or
both clavicle.

Indication: - Dead fetus with shoulder dystocia (anencephaly to be
excluded)
Procedure- Definition is self explanatory
Prerequisite are same as for craniotomy
Post Operative Care of mother following Destructive Operation

(i) Explore uterovaginal canal, for any laceration or trauma and manage
accordingly
(ii) Keep Self retaining catheter in the bladder for 4-5 days
(iii) Consider IV fluid and or Blood to correct dehydration and huypovolemia

172
 (iv) Cover with Double or triple broad spectrum antibiotic .
E) Complications of destructive operations:-

I) Trauma to Birth canal

II) Post partum hemorrhage. Atonic or traumatic
III) Shock hypovolumic or septic
IV) Puerperal sepsis
V) Injury to the adjacent organs causing
a) VVF, Urethro vaginal fistula
b) Recto Vaginal fistula
VI) Chronic morbidity in the form of psychophysical ill health

173
 Inter-sexuality

Definition: When factors, responsible for reading a particular sexual orientation in

one direction, head into different direction, inter-sexuality develop.
Four basic phenomenon are for sexual differentiation:
o Genetic sex [XX, XY]
o Gonadal sex [Ovary, Testis]
o Mullerian Inhibiting Factor (MIF) for development of male genitalia.
o Absence of MIF for development of female genitalia.
When four above factors do not work in proper direction, inter sex results, presenting
mainly in ambiguous genitalia in childhood with or without pubertal and menarcheal
problem in adolescence or late adolescence.

Diagnosis of Inter-sex:

o History including family and sibiling in detail

o History of drugs taken by mother during pregnancy
o Physical and general examination with special attention to
Age & growth relationship
Age and weight relationship
Male/Female habitus
Gait. Musculo skeletal system
o Sex of rearing
o Development of precocious Sexual character: Secondary sexual
characteristics
Precocious
Normal
Under or poorly developed
External
Size of clitoris (should not more than 0.6 cm2
Urethral placement, female or male type
Phallus normal micro or large for age.
Scrotum if present with or without gonad
Vagina present or absent
Any developmental anomaly of urogenital sinus.
o PV Exam or P/R for virgin

174
 o Breasts development (Tanner I to V)
o Detail systemic examination
o Barr body from Buccal Smear/ CBC
o Karyotyping with detail chromosomal work up
o Ultrasonography of abdomen & pelvis
o Abdominal organs
o Kidney, ureter, bladder
o Gonads
o Mullerian system
Uterus with tubes normal /infantile/anomalus or absent

Laparoscopy to confirm above and perform gonadal biopsy

o Laparotomy for gonadal biopsy and or gonadectomy if indicated.
o Gonadotropins/ sex steroids/ corticosteroide/ thyroid estimations
o Serum electrolytes incase of congenital Adrenal hyperplasia.
o IVU to rule out Renal anomalies
o CT/MRI superior to USG for Abdomen, Chest & Brain Scan,
o Psychological evaluation as & when indicated.
NB.
o Above diagnostic protocol needs to be followed
o In case of missing investigations difficult to pinpoint the diagnosis
o At the sometime even with full diagnostic work up correct diagnosis may
be difficult.

Principles of Management of Inter sexuality:

New Born: -
o Along with oropharynx and opening always examine external genitalia
o Any ambiguity needs specialist advice
o Thereafter counsel parents about possible future plan of action.
o Hands & feet edema points to turners
o Ambiguous genitalia could be simple labial fusion.
Infant:-
o Degree of virilisation
o Look for vomiting and weight loss etc.
o If both present suspect congenital Adrenal hyeperplasia (CAH)
o Barr body to confirm genetic sex (XX)
o USG to confirm/rule out Mullerian system and or gonadal

175
 o CAH must be treated properly with help of endocrinologist for future
normal development and to avoid mortality.
o Any other abnormality than CAH could be only followed up for proper
treatment at or after puberty.
o Parents shall need counseling.
Adolescence: -

o At puberty or after puberty (12-16 yrs)

o Beyond age of 16 yrs.
o Follow the clinical work up as per table after detailed examination and
investigation as per diagnosis section above.
Management of special conditions

CAH Medical hormonal (steroide)

Virilising Tumors Surgery/ medical
Testicular Feminisation syndrome Removal of ectopic Gonad
Refenstein/Klienferter syndrome Mainly hormonal (Androgen)
psychotherapy
Pseudovaginal perineo
Scrotal Hypospadi as Reconstruction to female genitalia
Plus estrogen HRT
True Hermaphrodite If assigned male sex as sex of rearing
and normal functional phalus then not
to change.

Otherwise Phallus (if micro) to be

excised

Orotestis to be removed

Steak ovary to be removed

Assign female role
If one side testis & other side ovary
then testis to be removed
Male Hermaphrodite
Due to Y defect Assign female role
Remove micropenis
Or reduce size

176
Mixed Gonadal Dysgenesis
MRKH Syndrome (Mullerian
Agenesis)
Urogenital sinus abnormality
Combined with intersex
Turners syndrome
Gonadectomy of ovotestis/ streak
ovary
Assign female role
HRT to get breast development and
menstruation phallus to be excised
Follow for Endo hyperplasia every 4-6
months.
Streak ovarian in this condition not
removed.
Neovagionoplasty
Urologist and gynecologists both
should treat jointly.
-Estrogen + Progestron HRT
-Follow for endometrial hyperplasia
every 4-6 month
-Streak ovary in this condition not
removed
177
 HIV-1/AIDS in OBGYN
According to the current estimates about 3.2 million people are infected with HIV
and probably the true number of AIDS cases since the beginning of the epidemic in
It is to be noted that 96 - 100% of HIV-1 strains have been found to be of subtype C.
Of the 36.1 million PLWHA worldwide, 70% are in sub - Saharan Africa where 70%
of all newly infected people reside and of which 55% of HIV positive adults are
women.Gender inequality and biological factors make women more vulnerable for
HIV infection.
About 87% of reported new HIV infections in adults were due to the practice of
multiple sexual contact and the estimated rate of vertical transmission in Ethiopia is
claimed to be over 29%.

Every year of the estimated 10 million women worldwide, who are infected with
HIV/AIDS, two million become pregnant and HIV/AIDS is transmitted during
pregnancy and childbirth to approximately 600,000 infants in the developing world-
1600 children every day. Of women who have not received any preventive treatment
transmission to the infant occurs in approximately one third of births by HIV positive
women.
Two thirds of these transmissions occur during late pregnancy and delivery: one third
occur during breast-feeding if the woman has established HIV infection during
pregnancy.
HIV - infected women are more likely to develop recurrent vaginal candidiasis,
venereal warts, cervical dysplasia, carcinoma in situ and overt cervical carcinoma.

Mother - to - child transmission (MTCT) means transmission of HIV to a child from

an HIV - infected woman during pregnancy, delivery and breast-feeding. The term
"vertical transmission" is commonly used interchangeably with MTCT.

Gynecologic and Family planning care for the woman infected with HIV
Common gynecologic problems in hiv infected women and management options
Menstrual disorders:
Menorrhagia, menometrorrhagia, oligomenorrhea, Amenorrhea
MANAGEMENT:
Similar evaluation and treatment as those women without HIV infection
STDS: STDs increase susceptibility and infectivity to HIV. HIV as well increases
the severity of STI and Increases the susceptibility to the development of genital
ulcers.

178
 SYPHILIS: -
Serologic titers may be false positive, false negative or delayed positive
CSF examinations before treatment: - Indicated for late latent or syphilis of
unknown duration & for neurologic symptoms or treatment failure in
primary, secondary and early latent syphilis.
MANAGEMENT: -
If Negative finding in CSF manage as Primary, secondary, or latent syphilis
with 2.4 million units of benzathine penicillin IM weekly for 3 doses
Follow-up VDRL: 3, 6, 12 and 24 months
If Abnormal CSF with Inflammatory cells, increased protein, or positive
syphilis serology in CSF treat with IV aqueous penicillin, 4 million units
every 4 hours for 10 to 14 days.
Follow-up VDRL: 6, 12, 18, 24 months.
PELVIC INFLAMMATORY DISEASE:
Hospitalization for inpatient treatment should be strongly considered using
parenteral antimicrobial regimens.
VAGINAL CANDIDIASIS:
Treat topically on intermittent or continuous basis for 7 - 14 days.
Avoid systemic antifungals
WARTS (EXOPHYTIC GENITAL WARTS):
More common, tend to be larger, more often multicentric, and more difficult
to treat. Treat as in other cases.

Dysplasia

More aggressive, more often higher grade, more likely persist and progress
Less likely to regress.
Pap smear screening should be performed at baseline, repeated at six months
and annually there after.
Clinicians must have a low threshold for performing colposcopy
CONTRACEPTION

Condom
Preferred contraceptive methods, Since only condoms can reliably reduce HIV risk to
uninfected partners. It prevents cross infection among HIV infected partners and offers
excellent protection when consistently and correctly used for every sexual act. It may be
used in combination with other contraceptive to reduce HIV risk.

179
ORAL CONTRACEPTIVE PILLS:- can be used along with barrier methods.
However there is inverse association between OCP and Condom use .
PROGESTERONE CONTRACEPTIVES (DEPO - PROVERA, NORPLANT)
Reduced efficacy in preventing pregnancy
Exacerbate anaemia
Increase risk of PID
IUDs: should not be used by HIV positive women
SPERMICIDES (NONOXYNOL 9)::
Prolonged use of high concentration cause mucosal inflammation and disruption.
Permanent sterilization (Tubal ligation)::
Decrease in condom use
Counseling and Voluntary HIV testing

Prevention of Mother to Child transmission (PMTCT)

Factors affecting MTCT of HIV-1

VIRAL Viral Load
VIRAL GENOTYPE AND PHENOTYPE
Viral resistance
MATERNAL Maternal immunological status
Maternal nutritional status
Maternal clinical status
Behavioral factors
Placental factors
Antiretroviral treatment
OBSTETRICALProlonged rupture of membranes (>4 hours)
MODE OF DELIVERY
Intrapartum hemorrhage
Obstetrical procedures
Invasive fetal monitoring
FETAL Prematurity
MULTIPLE PREGNANCY
INFANT Breast-feeding
GASTROINTESTINAL TRACT FACTORS
Immature immune system

180
CARE OF THE PREGNANT HIV - INFECTED WOMAN
ANTEPARTUM HISTORY
Complete history identifying - Current HIV related symptoms, medications, care,
- Sexual risk behaviors, STI Family and social history with review of systems.
PHYSICAL EXAMINATION
General HIV Specific
Obstetric & Gynaecologic STD - Survey
LABORATORY STUDIES
CBC Hgb Platelet count
STD screening (Vaginal wet mount, GC,)
Syphilis testing (Repeat testing in late pregnancy may be advisable)
RFT, LFTs and Hepatitis B surface antigen

CD4+ and CD8+ cell count and percentages initial visit, repeat 24-28 wks, 32
- 36 wks (if possible)
Total lymphocyte count (where CD4 cell count is not available)
PPD
Viral load estimation (if possible)
CXR (when clinically indicated)
Pap smear if this has not been undertaken within the recent past
Colposcopy for abnormal cervical smear
Ultrasound: Baseline at 16 - 18 wks
o To more accurately assess GA
o To screen for fetal anomalies
Early ultrasound
Uncertain dates
If patient requests termination and abortion is legal
Serial ultrasound examination
Each month until the 36th week of gestation, every 2 wks until
the 40th week, and weekly thereafter until delivery.

FETAL MONITORING
o Baseline ultrasound 16 - 18 wks
o Other fetal assessment as indicated
Frequency of prenatal follow-up:
Once per month until 28 wks (Consider q 2 wk visits if CD4 <
200/mm3 ), then q 1-2 wks until delivery

181
MISCELLANEOUS
Information & counseling
- Information about HIV/AIDS and its prevention
Partner HIV testing
- Adequate treatment of STDs
Termination of pregnancy within the sanctity of the law
- Hospital delivery
Risks and benefits of C/S
- Infant feeding option
ARV and etc.

Avoid invasive diagnostic procedures (CVS, amniocentesis,

cordocentesis)
Avoid ECV
Prophylaxis against:
- Malaria, Tuberculosis, P.carinii pneumonia,
Toxoplasmosis, M. avium and etc.
Behavioral interventions
Detecting and Treating
- STDs and HIV - related opportunistic infections
Prevention of Perinatal Transmission
1. LONG COURSE ZDV REGIMEN STARTING FROM EARLY
PREGNANCY
HIV infected women without prior ARV:
Pregnancy: AZT (300mg bid, 200mg tid or 100mg 5x/day) initiated at 14 - 34
weeks of gestation and continued to onset of labor.
Labor: IV AZT (Loading infusion of 2 mg/kg IV for one hour followed by
continuous infusion 1mg/kg per hour until delivery)
Infant: AZT for the newborn (AZT syrup at 2mg/kg every six hours) for the first
six weeks of life beginning 8 - 12 hours after birth.

2.HIV infected women receiving antiretroviral therapy

If the regimen does not include AZT, this drug should be added or substituted, but
should not be added to a regimen that includes d4T
In the first trimester recommendations should be made based on clinical findings
(CD4 count, viral burden, symptoms, etc) and the patient's decision based on
available information through informed consent.

182
 Intrapartum and newborn AZT is recommended regardless of the ARV regimen.

3. SHORT COURSE ZDV REGIMEN STARTING GENERALLY ONE MONTH

BEFORE DELIVERY
Pregnancy: AZT 300mg bid starting wk 36
Labor: AZT 300mg q3h
Infant: none,
or
Pregnancy: AZT 300mg bid starting wk 36 - 38
Labour: AZT 600mg
Infant: none
Postpartum: AZT 300mg bid x 1wk
REGIMENS STARTING IN LABOUR (ZDV OR NVP REGIMENS)
HIV Infected women in labour without prior therapy
Labour: AZT IV loading 2mg/kg/1hr followed by 1mg/kg/hr until delivery.
Infant: AZT syrup 2mg/kg every 6hrs for the first 6 wks
NVP
Labour: 200 mg stat
Infant: 2mg/kg during the first 72 hours of birth.
* If NVP was not given during labour or was given shortly before delivery, neonate
should receive the drug at birth.
Infant born to woman who received no treatment during pregnancy or
intrapartum:
Treat the infant with the 6 wk course of AZT + an additional ARV agent
beginning within 48 hours of birth.

Monitoring mothers who received ZDV prophylaxis

Hct, Neutrophil count, SGOT and SGPT once monthly
Cessation or interruption of therapy if:
- Hgb < 8 g/dl
- Neutrophil count < 750-cells/l
- SGOT / SGPT more than five times normal
INTRAPARTUM CARE:
Use universal precautions
Avoid ARM if possible
Avoid invasive monitoring procedures
Selective use of caesarean sections

183

Restricted use of pudendal anesthesia

Avoid episiotomy if possible

In the presence of meconium, use wall suction for oropharyngeal suction of
newborn
ARV
POSTPARTUM CARE:
Injections and heelsticks for blood sampling should be delayed until after the
neonate has been bathed.
Protease inhibitors potentiate the effect of ergotamines.
Private facilities for those not breast-feeding.
Mother should be given information on the early symptoms of infection at the
time of discharge
Instructions on perineal care and safe handling of lochia and blood stained
materials
Information on how to care for their babies without the risk of exposure to
infection.
Informed decision after counseling on the full range of infant feeding options.
Exclusive breast feeding followed by early cessation of breast feeding(up to 3
months)
Heat treatment of expressed breast milk (62.50 c for 30 minutes)
Wet-nursing by a tested HIV negative women
If artificial feedings chosen, teach her how to prepare the feedings and how to
feed the infant from a cup and discuss strategies for lactation suppression.
Those breast feed must be treated promptly for breast infections and cracked
or bleeding nipples.
Infants that have thrush, ulceration or other problems of the mouth should be
treated.
Contraception and safer sex counseling
Arrangements for ongoing HIV primary medical and pediatric care.

PREOPERATIVE PREPARATION
Note: It is advisable to do tests for HIV especially before a major operation
1. Elective operation
If patient is infected and/or has AIDS elective operation is done only if that
will significantly lengthen the patients life expectancy. The patient is
considered a poor risk if :CD4 cell count is < 200/mm3 & T-cell count is low.

184
 2. Emergency operation
Patient is managed like any other women with absolute observation of
universal precaution against infection prevention.

Universal Precautions: Precautions that should be practiced by every

practitioner to prevent occupational exposure as well as transmission of
disease among patients. Therefore one should:
Reduce needle stick injuries by handling used needles as little as possible,
using a needle holder during episiotomy, avoiding recapping disposable
needles and taking great care in recapping blood sampling barrel system
needles or non disposable syringes, placing needles and other sharps in the
appropriate containers.
Wash hands with soap and water immediately after contact with blood or
body fluids.
Wear suitable gloves when expecting exposure to blood or body fluids.
Cover broken skin or open wounds with watertight dressings.
Wear an impermeable plastic apron for delivery.
Wear eye shield for operating or assisting at cesarean section, and for
suturing episiotomies.
Wear double gloves, if possible, for all operations, which reduce considerably
the amount of blood carried through if a glove is punctured.
Use an appropriate sized needle (21gauge, 4cm. curved) for the repair of
episiotomy, together with a technique using a needle holder.
Pass all sharp instruments onto a receiver, rather than hand-to-hand at
cesarean section and modifying surgical practice to use needle holders and to
avoid using fingers in needle placement.
Use long- cuffed gloves for manual removal of a placenta.
Wherever possible, avoid the need for suction of newborns and using wall
suction or a suction machine when suction is required.
Dispose of solid waste such as blood soaked dressings or placentas safely.

185
 Post - exposure prophylaxis for health care workers
Immediate treatment:
Decontamination of the exposure site as soon as possible,
Allowing a needle stick injury or cut to bleed,
Washing the area with chlorhexidine or other antiseptic
Decontaminating exposed mucosa or conjunctivae by vigorous flushing with
water.
Assessment of risk following exposure
A. THE NATURE OF THE INJURY:
Puncture: type of needle, depth of penetration and volume of blood
Laceration
Mucosal contamination
Contamination of non-intact skin
Bite
B. THE SOURCE OF EXPOSURE:
Blood, blood products, body fluids, amniotic fluid, semen and vaginal
secretions are associated with transmission of HIV, while stool and urine are
not.
C. THE SOURCE PATIENT:
The clinical stage of the disease
Clinical condition or available laboratory results such as viral load.

PEP should be initiated preferably within 1 - 2 hours of exposure.

If the exposure does not bring a known risk of HIV (If source is sero-negative, or
if exposure is on intact skin
May not consider PEP
If the Sero-status of the source is not known
Consider the type of exposure
The likelihood of the source to be HIV positive
The clinical state of the source
If the above mentioned points indicate likelihood of exposure to HIV
Consider basic regimen
If Exposure type poses negligible risk
High HIV titer in the source
Non-intact skin exposure

186
Consider basic regimen
If exposure is less severe
Solid needles major blood splash or longer duration of exposure, superficial scratches
low titer of HIV in the source

Consider basic regimen

If exposure is of high risk
Major splash, larger dose, longer duration solid needle superficial scratch and higher titer
of HIV in the source, consider expanded regimen
If exposure is of high risk
Large bore hollow needle, deep puncture, lower or higher titer

Consider expanded regimen

Basic regimen is a two-drug regimen

Zidovudine 600 mg/day in two or 3 divided doses and
Lamuvudine 150 mg two times /day

Expanded regimen includes basic regimen plus Indinavir 800 mg 8 hourly or Nefinavir
750 mg 8 hourly
Timing of PEP: PEP should be started as soon as possible following exposure but not
later than 24 hours
Optimal duration of treatment: is not exactly known but is recommended to continue
for four (4) weeks

Counseling and testing of the health worker

HIV serology should be performed at the time of injury and repeated at 6 wks,
3 months, 6 months and 1 year.
For six months
Advice to practice safe sex,
Avoid blood donation and
Consider delaying pregnancy.

187
 The management of abnormal uterine bleeding (AUB)

AUB is one of the commonest problems that challenge the gynecologist. Virtually, every
woman will at some point in her lifetime experience episodes of bleeding that will be
perceived as abnormal. The abnormal bleeding can be caused by a wide variety of
disorders. It may represent a normal physiologic state, and observation alone may be
warranted. Alternatively, the bleeding can be a sign of serious underlying conditions,
necessitating aggressive treatment that would include hysterectomy.

Normal Menstruation
Menstrual blood is predominantly arterial the usual duration of flow is 3-8 days, amount
does not exceed 80ml, the cycle ranges from 21-35 days and usually is asymptomatic.
Abnormal Uterine Bleeding:
Any bleeding from the uterus, that differs from the usual menstrual cycle in frequency,
amount, duration of flow or time of the occurrence is considered

Dysfunctional uterine bleeding (DUB)

Dysfunctional uterine bleeding (DUB): is AUB for which no specific organic cause can
be found, after a thorough evaluation and work up of patient. AUB that occurs during the
extremes of a womans reproductive life is usually as a result of anovulation (DUB).
AUB that occurs in a woman of reproductive age group (15-40) should be
considered the result of complication of pregnancy until proved otherwise.
Therefore, organic causes must always be excluded before the diagnosis of DUB
is made.
All women with history of high risk factors for coagulation disorders; all
adolescents with excessive and prolonged periods; women with anovulatory
DUB, in whom medical therapy has failed and women with ovulatory DUB
without anatomic uterine lesions should be screened for coagulation disorders.
AUB occurring in women of peri-menopausal (>40 years) or post-menopausal age
should be considered as a result of malignancy until proved otherwise.

Steps in the Evaluation of AUB

HISTORY
Age, parity, marital status, sexual history
Detailed menstrual history, regular menstrual cycle proceeded by molimina
symptoms is highly predictive of ovulation.

188
 Pubertal milestones, previous gynecologic diseases
Contraceptive history and other medications, symptoms of PID
Symptoms of stress and psychiatric abnormality
Symptoms of endocrine other organic diseases
Bleeding tendency and family history of bleeding disorders

PHYSICAL EXAMINATION
General appearance:
Stigmata of endocrine diseases, liver disease and anemia, signs of bleeding
tendency, vital sign, and examination of the other organ systems.
Pelvic examination:
Optimal in all patients and essential in those who are sexually active
Inspection for secondary sexual characteristics, vaginal trauma, sign of
infection, atrophic virginitis and foreign body.
Speculum examination and bimanual examination:
* In non-sexually active adolescents, a recto-abdominal examination is performed to
rule out a foreign body and to palpate the cervix.

LABORATORY EVALUATION
Hemogram: CBC, Hgb
Pregnancy test for all women in the reproductive age group
Recurrent, severe bleeding or menarcheal onset: Coagulation profile, LFT,
TSH
Test for STD (chlamydia, gonorriahea, trichmoniasis)
Pap smear: for sexual active teens and women above the age of 18yrs who are
not bleeding at the time of examination.
Tests for ovulation: BBT, serum progesterone, endometrial biopsy, ferning
test
Chronic anovulation with irregular bleeding: LH/FSH, Prolactin
AUB with hirsutism: Testosterone, 17keto-steroids.

Reproductive or Perimenopuasal women; to evaluate endometrial pathology:

Endometrial biopsy/hysteroscopic endomentrial sampling
Manual Vacuum Aspiration (MVA) or D &C
Ultra-sonography
Indications for endometrial sampling
In a women above 35 years of age

189
 Those > 30years with long term history suggestive of oligo-ovulation or
anovulation
Exposure to unopposed estrogen
At younger age in woman with chronic anovulation
In women with sign and symptom of chronic endometritis
Obese women
Post-menopausal women on hormone replacement therapy (HRT)
Tamoxifen treatment
* CT/MRI are rarely needed for pelvic mass that is not clearly seen by sonography.

Management of AUB

The management of AUB depends on the etiology of the bleeding .In identifiable causes,
the treatment is targeted to wards the cause: e.g hypothyroidism, coagulopathy,
iatrogenic, pregnancy etc
The management of DUB depends on:
Age of patient
Severity of bleeding
Desire for future fertility
Presence of associated pathology
The whole objective of treatment should revolve around the following points;
Control bleeding
Prevent recurrence
Preserve fertility
Induction of ovulation in women who desire to conceive
Correct associated disorders
MEDICAL TREATMENT
This modality of treatment is preferred if the patient desire future fertility and has no
associated pelvic lesion. Patients with mild DUB need reassurance only.

Control Heavy Bleeding

1. High dose estrogen:
Promotes rapid endometrial re-growth to cover denuded epithelial surfaces.
Conjugated equine estrogen: Orally: 10mg a day, in four divided doses or IV: 25mg,
every 2 to 4 hours for 24 hours. Usually bleeding stops within 24 hours of initiation
of treatment. Once the bleeding is controlled with IV high dose conjugated equine
estrogens, the patients are switched to oral estrogen 10mg a day for 21 to25 days and

190
 oral medroxyprogesterone acetate 10 mg a day is administered concomitantly with
the estrogen for the last 7-10 days.
2. High dose COC Pills:
Three to four tablets a day. Once bleeding stops, treatment is continnued for at least
one more week. Once the acute bleeding episode is successfully controlled, the
patient can use standard dose-combined oral contraceptive pills (COC) regimens, one
tablet/day for 21 days, or medroxyprogesterone 10mg daily for 10days each month
for 2-3 months. This is not as effective as high dose estrogen.

PREVENTING RECURRENCE:
Anovulatory DUB:
o Progestin therapy is preffered by many people. Progestin stops endometrial
growth and supports and organize an estrogen- primed endometrium. When
progestin therapy is withdrawn, an organized slough of the functional layer of
the edometrium occurs, which permits a rapid cessation of the bleeding when
there is adequate endogenous estrogen.
o Oral medroxyprogesterone acetate; 10mg a day for the first 10 days each
month or days 16 through 25 of each cycle may be given.
OR
o Norethindrone: 5-10mg, one to three times a day for 10 days. For
those difficult to treat, the course progestin can be extended for 14 to 21 days.
OR
o COC Pills.

Ovulatory DUB:
The underlying cause is imbalance in prostaglandins.
NSAIDs: have the discriminatory ability to block PGI2 (a vasodilator that
inhibits platelate aggregation) without suppressing TXA2; e.g
Mefenamic acid 500mg 3 times a day; this drug is more effective because it
acts on already synthesized prostaglandin; or Ibuprofen 400 mg 3 times a
day; or Naproxen Na, 275 mg four times after a loading dose of 550mg.
These drugs are given either throughout the bleeding or the first three days of
menses.
NSAID and COC
Danazol: 200-400mg daily for 12 weeks.
GnRH agonists: medical menopause (decrease blood loss and induces
amenorrhea), last resort when all modalities fail.

191
B. SURGICAL TREATMENT
D&C: fastest to stop bleeding in patients who are hypovolemic with
menorrahagia
In age above 40 years: it must be done
Age 20 to 40 years: postponed
Age less than 20 years: should be defferred
Hysterscopy and Resection of endomerial pathology
Hysterectomy:
In girls and young women should be last resort
In women in their thirties should be performed with reluctance
In older women (>40 years) should be considered in all cases of
persistent or recurrent bleeding, particularly after a repeated
curettage or other methods failed and presence of other pathology;
e.g. pelvic relaxation, myoma.
Endometrial ablation: LASER, Electrocautery

192
 Algorithm for evaluation of a Patient with AUB

History, Physical exam, Pertinent

History, Physical Exam Lab Studies

HCG Positive Pregnancy

evaluation

Negative

DUB Pelvic examination Lesion

No Lesion

If >35 years Evaluation

- Endometrial Biopsy Specific therapy
- Hysteroscopy
- Vaginal Ultra Sound

Negative DUB Refractory Coagulation

bleeding Studies
Hepatic/thyroid
function test

193
 The Management of Abortion and Post Abortion Care

Abortion is a common health problem. At least 15% of all pregnancies end in

spontaneous abortion. Unsafe abortion is a major public health problem and at least 20
million women undergo unsafe abortion each year. Abortion complications are
responsible for around 14% of the approximately 500,000 maternal deaths that occur
each year and with millions of others suffering chronic morbidities and disabilities. In
Ethiopia maternal losses from abortion and its complication account for 25-50%.

The key elements of post abortion care are:

Emergency treatment of incomplete abortion and potentially life threatening
complications
Post-abortion family planning counseling and services
Links between post-abortion emergency services and the reproductive health care
system

Definitions OF TERMS

Abortion: is the process of termination or expulsion of the pregnancy before the 28th
completed weeks of gestation or less than 1000gm weight.
Unsafe abortion: characterized by lack or inadequacy of skill of provider, hazardous
technique and unsanitary facilities or both.
Recurrent abortion: three or more consecutive spontaneous termination of pregnancies.
Therapeutic abortion: Termination of pregnancy before the time of fetal viability for the
purpose of saving the life of the mother (3)
Septic abortion: When any of the stages of abortion complicated by pelvic infection.

194
Clinical Stages of Abortion
Stage Bleeding Cervix Uterine Other Signs
size
Threatened Slight to Closed Equal to Abdominal
abortion moderate date cramps, soft
uterus
Inevitable or Slight to Dilated Less than Cramping
incomplete moderate or equal to Tender firm
abortions date uterus
Leakage of
liquor
bleeding for 7
days or more
Bleeding to
drop in Hgb or
shock
Partial expulsion
of products of
conception
Complete
Less than
Complete Slight to expulsion of
Dilated or equal to
abortion moderate products of
date
conception
Dead fetus
Less than
Missed Little or Decrease in
Closed or equal to
abortion none pregnancy signs
date
and symptoms

195
Initial assessment
In any women of reproductive age experiencing at least two of the following
symptoms, abortion should be considered.
Vaginal bleeding
Cramping and/or lower abdominal pain
A possible history of amenorrhea
Complete clinical assessment is necessary to determine all conditions that are present
in order to decide the order in which to treat them.
History: Ask about the following
Length of amenorrhea
Bleeding (duration, amount)
Cramping (duration and severity)
Abdominal or shoulder pain
Drug allergy
History of interference
Method employed
Symptoms of infection
Physical examination
Check V/S (T, PR, RR, B/P)
Note general health of the women
General systemic examination
In abdominal examination
Check bowel sound
If abdomen is distended
Location and severity of tenderness & rebound tenderness.

196
 Pelvic examination
Remove any visible products of conception from the vaginal canal or
cervical OS
Note
The amount of bleeding
The cervical dilation status
Presence of foul smelling discharge
Check for cervical laceration
Bimanual examination
Estimate size of the uterus
Check for any pelvic mass
Check for tenderness in the pelvis

Laboratory examination
Hgb/ Hct, blood group & Rh
Based on clinical assessment when indicated
WBC,ESR
Urinalysis
RFT, LFT
Platelet count, PT, PTT
Plain film of the abdomen (Erect)
Pelvic ultra-sonography, Pregnancy test as indicated
Management
Threatened abortion
Bed rest
Avoid intercourse Douching
Monitor progress
- Subsequent assessment
- Ultra-sonography-for viability
If any sign of pelvic infection Evacuate the uterus after antibiotic coverage
Complete abortion
Examine concepts carefully for completeness
Ultrasound to see retained tissue
Document completeness on referral paper
If any doubt of completeness evacuate the uterus
Administer ergometrine 0.5mg
Methods of Uterine evacuation is determined by uterine size

197
 If uterine size < 14 weeks
MVA/EVA
D&C
E & C if cervix is open
If uterine size > 14 weeks
Prostaglandin
Oxytocin
E & C /D & C D and E when appropriate
Condom catheter + Oxytocin
Hysterotomy
Laminaria tent
Oxytocin administration
Add 10ml(ampoules) to 1000ml lactated Ringer's solution (100mu/ml)
Start at 0.5ml/mi (50mu/ml), increase at 30 to 40min intervals up to a maximum rate
of 2ml/min (200mu/min). If effective contractions are not established at this infusion
rate, increase the concentration. Discard all but 500ml of the remaining solution. Add
additional 5 ampoules of oxytocin (200mu/ml). Reduce the rate to 1ml/mi
(200mu/mi). Increase up to 2ml/mi (400mu/mi), continue at this rate for 4-5hrs or
until fetus is expelled.

Management of Complications

Uterine perforation
The following signs indicate perforation during uterine evacuation.
An instrument (sound, Cannula, Curette) extends beyond the expected limit
of the uterus.
Fat or bowel is found in the tissue removed from in the uterus
Severe pain
Unstable vital signs
hypotension in the absence of external bleeding

Management
Stabilize the patient
Monitor V/S I f unstable Hypo tension consider immediate Laparatomy
Start broad spectrum antibiotics (parenteral)
If evacuation is complete

198
 Give ergometrine 0.5ma
If evacuation is not complete, Complete evacuation under direct visual
control ( laparatomy)
If patient become stable and bleeding slow, give ergometrine and continue
observation overnight .If the condition gets worse and the bleeding doesnt
stop, do Laparotomy / Laparoscopy
Repair or hysterectomy based on operative findings

Intra abdominal injury

The following signs and symptoms indicate intra abdominal injury
Symptoms
Nausea, vomiting
Shoulder pain
Fever
Abdominal pain and cramping
Signs
Distended abdomen
Decreased bowel sound
Tense hard abdomen
Rebound tenderness
Management
Resuscitation
IV antibiotics
Laparotomy

Sepsis
Etiology is poly microbial
The following symptoms and signs indicates that either local or generalized infection
is likely:
Symptoms
Chills, fever, sweating
History of interference
IUD in place
Prolonged bleeding
General discomfort, flue like symptoms
Signs

199
 Foul smelling vaginal discharge
Distended abdomen
Tenderness
Low blood pressure
Assess womens risk for developing septic shock
Low risk
First trimester abortion
Mild to moderate fever (< 38.50 c)
Stable V/s
No evidence of intra abdominal injury
High risk
2nd trimester abortion
High fever (> 38.50 c)
Any evidence of intra abdominal injury
Shock
Management
Resuscitation
Monitor V/s
Start broad spectrum antibiotics IV
If low risk and stable
Uterine evacuation
Continue antibiotics
Observe for 48 hrs.
If high risk
Continue antibiotics
manage shock, intra abdominal injury, DIC accordingly

POST ABORTION FAMILY PLANNING

All women receiving post abortion care need counseling and information to ensure
that they understand: -
They can become pregnant again before the next menses
There are safe methods to prevent or delay pregnancy
Where and how they can obtain family planning service

200
Annex 1: Antibiotic choices
Use empiric therapy to cover wide variety of Aerobic, anaerobic, gram
negative/positive organisms.
Regimens

1. Ampicillin or benzyl
penicillin

Plus

Chloramphenicol or
Clindamycin or
metronidazole
Plus

Gentamycin

2.
Ceftriaxone Gentamycin
Plus or or
Ciprofloxacin metronidazole

3. Doxycycline with metronidazole

Once started, therapy can be continued until the patient is afebrile at least for 24
hours, preferably 48 hours
If there is no response in 48 hours the antibiotics should be changed/complications
considered
When recovery is underway, IV therapy should be followed by oral medication, for
10 to 14 days.

201
Annex 2: Pain control for E and C, D and C or MVA/EVA

To select appropriate pain management medications one must consider the

conditions present, the timing and route of administration and precaution for each
type of medication.

I. Analgesics (PO, IM or IV)

Mild or moderate pain anticipated
paracetanel or Ibuprofen PO 30-60 minute before procedure
Moderate to severe pain
Meperdine (pethidin), Codeine
II. Anxiolytics (PO, IM, IV)
Diazepam 5-10 mg IV or 10 mg PO 1 hr before procedure
Midazolam 0.5 1mg IV
III. Local anesthesia :Paracervical block (for cervical dilatation)

IV. Combination of drugs

Paracervical block + Analgesics
Analgesics + Anxiolytics
Diazepam + Meperdine
Midozolam + Fentanyl

202