Skilled Birth Attendance Care During Labour, Delivery and Postnatal Periods at 24/7 PHCs
Item
- Title
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Skilled Birth Attendance Care
During Labour, Delivery and
Postnatal Periods at 24/7 PHCs
- extracted text
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Mentors'Manual
Skilled Birth Attendance Care
Volume: 2
During Labour, Delivery and
Postnatal Periods at 24/7 PHCs
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)T KHPT
Karnataka Health Promotion Trust
15JSb |
Mentors'Manual
Volume
Skilled Birth Attendance Care
During Labour, Delivery and
Postnatal Periods at 24/7
Primary He3 Ith C^ntrpQ
Sukshema
Maternal, Neonatal an
SOCHARA
Community Health
Library and Information Centre (CLIC)
Community Health Cell
85/2, 1st Main, Maruthi Nagar,
Madiwala, Bengaluru - 560 068.
Tel: 080-25531518
email: clic@sochara.org / chc@sochara.org
www.sochara.org
An overview of the On-Site mentoring intervention to institutionalize quality improvement
strategy within 24/7 Primary Health Care centers in Karnataka state. The philosophy, design,
The philosophy, design, implementation process and results are detailed herein.
Copyrights
:
Year of Printing :
Publisher
:
Karnataka Health Promotion Trust and St John's National Academy of Health Sciences
2014
Karnataka Health Promotion Trust
IT Park, 5th Floor
# 1-4, Rajajinagar Industrial Area
Behind KSSIDC Administrative Office
Rajajinagar, Bangalore- 560 044
Karnataka, India
Phone:91-80-40400200
Fax:91-80-40400300
www.khpt.org
This process document is published with the supportfrom the Bill & Melinda Gates Foundation under
Project Sukshema. The views expressed herein do not necessarily reflect those ofthe Foundation.
Mentors' Manual Volume 2
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Government of Karnataka
Department of Health and Family Welfare
National Health Mission
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PREFACE
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Institutional deliveries in Karnataka have risen over recent years due to the efforts by the state health
directorate which were strongly complemented by various innovations and schemes implemented under
the National Rural Health Mission (NRHM) such as Janani Suraksha Yojana (JSY) and Janani Shishu Suraksha
Karyakram (JSSK), ASHA support, 108 ambulance services, etc. There has been a reduction in maternal and
newborn mortality rates (MMR, NMR), but not enough to achieve the proposed state targets. With over
80% of pregnant women now delivering in facilities, it is critical that these deliveries are conducted as per
the highest standards for quality of care. To accommodate this rising demand, government had prioritized
upgradation of Primary Health Centres into 24/7 facilities to provide delivery services in rural areas and
reduce the burden on district and larger hospitals enabling them to function more appropriately as first
referral units (FRU) to provide emergency care. To achieve good quality of services provided in public
health facilities it is important that the service providers working at these facilities are proficient in skills
and practices that are appropriate particularly with reference to pregnant women, mothers and new
borns. To facilitate this, the need for dedicated teams to improve and monitor quality is crucial.
As a part of technical assistance to NRHM, Karnataka Health Promotion Trust and its consortium of
partners developed an innovative nurse mentor led quality improvement program after detailed situation
assessment and consultations with government. It was pilot tested in Bellary and Gulbarga during 20122013 where trained Nurse Mentors worked with 24/7 primary health centres.(PHCs) staff to improve the.
quality of delivery and postpartum care. The mentoring programme integrated elements of clinical
mentoring with facility-based quality improvement processes. Another critical component of the
intervention was the use of revised case sheets by the staff that helped them in multiple ways, i.e. as job aid
to adhere to standard practices, as a simple case documentation tool and as a tool to monitor and audit
quality of care. The intervention results showed marked improvements in facility readiness and provider
preparedness to deal with institutional deliveries and associated complications. Subsequently the
program was scaled up in the remaining high priority districts of northern Karnataka and further taken up
both within and outside the country.
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As a part of this intervention, several technical products and training material were developed; they consist
of 1) process documentation of the intervention that details the process of planning, implementing and
monitoring the mentoring program, 2) Facilitator/ Trainer and Participant manuals. These materials have
as annexures within them, various tools including the case sheets that were implemented under this
initiative. We sincerely hope that these resources will be found useful by program managers in terms of
gaining an in-depth understanding of the intervention and replicating it in their respective contexts.
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Smt Sowjanya, i a.s
Mission Director
National Health mission
SrLP.S. Vast rad, i. a.s
Commissioner
Dept, of Health & Family welfare
Sri. Atul Kumar Tiwari, IAS
Principal Secretary,
Dept, of Health & Family welfare
..
Contents
Contents
Acknowledgements
v
About the Manual
vi
Abbreviations
viii
Glossary of Terminology:
xi
Chapter 1.
Maternal health Situation in northern Karnataka
1
Chapter 2.
Initial assessment at admission
5
Chapter 3.
Labour and delivery
28
Chapter 4.
Postpartum/postnatal period
60
Chapter 5.
Complications during pregnancy, labour, delivery and postnatal period Identification, Initial management and referral
Section 5. A
Identification of complications and initial management and
referral - General principles
Section 5.B
68
69
Prolonged or obstructed labour and rupture of
membranes more than 12 hours duration
73
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Skilled birth attendance care during labour, delivery and postnatal periods at 24/7 Primary Health Centres
Skilled birth attendance care during labour, delivery and postnatal periods at 24/7 Primary Health Centres
Section 5.C
Chapter 6.
Hypertensive disorders of pregnancy - Pregnancy induced
hypertension, pre-eclampsia, eclampsia
80
Section 5.D
Antepartum hemorrhage
93
Section 5.E
Infection or sepsis in pregnancy, labour and/or postnatal period
97
Section 5.F
Preterm labour/preterm or pre labour rupture of membranes
105
Section 5.G
Postpartum hemorrhage
109
Preparation for discharge
Bibliography
IV
Mentors'Manual Volume 2
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Acknowledgements
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Acknowledgements
The authors appreciate the support provided by numerous individuals over an extended period of time to allow
documentation of this important innovation. Special thanks to Dr B.M. Ramesh, former Project Director of Sukshema
Project, for recognizing the importance of documenting the mentoring programme so others can learn from
this activity and for the guidance provided throughout. Thanks to Anna Schurmann for helping to structure the
project's knowledge management strategy and to Baneen Karachiwala who provided independent observation and
interviews of the first mentor training. The dedication of project staff—including several Bangalore-based technical
leaders, support staff, and district programme specialists who coordinated numerous field visits to several districts—
ensured high-quality observations at primary health centres and insightful interviews with those implementing
the intervention. These staff include Dr Swaroop, Dr Mahantesh, Dr Seema, Dr B. Pavan, Dr Nazia Shekhaji, and
Laxshmi C. We thank the team from St John's Research Institute that included Dr Prem Mony, Maryann Washington,
Dr Annamma Thomas, Dr Swarnarekha Bhat, Dr Suman Rao and other consultants for their support in the trainings
and handholding visits and for sharing their experiences that have informed the process document. We appreciate
the support of clinical consultants from University of Manitoba, Lisa Avery and Maryanne Crockett for their support
during the design of the program. We also acknowledge the efforts of Dr Sudarshan and Dr Nagaraj from Karuna Trust
for their support to the implementation of the program. Appreciation is extended to Arin Kar, Deputy Director of
Monitoring and Evaluation, for providing data support and to H.L. Mohan, Director of Community Interventions and
Somshekar Hawaldhar, Deputy Director of the community intervention component for contributing to the discussion
on program coordination. Special appreciation is also due to the nurse mentors for their enthusiastic participation
in interviews and focus groups, and for facilitating the ability to observe their work in action. We thank the many
primary health centre staff and district government officials who met with us to share their candid views about the
mentoring programme. Finally, we thank Stephen Moses, Professor and Head of Community Health Sciences of Dr
James Blanchard, Director, Centre for Global Public Health, University of Manitoba for their valuable reviews and
inputSu
• - -
The funding support for development of this manual was provided by Bill and Melinda Gates Foundation.
The following institutions and individuals have contributed to development of volume 1 of the SUKSHEMA
Facilitator's Manual.
Karnataka Health Promotion Trust (KHPT)
St John's National Academy of Health Sciences (SJNAHS)
University of Manitoba (UoM)
Dr LTroy Cunningham, KHPT
Mrs Janet Bradley, UoM
Dr John Stephen SJNAHS
Ms Maryann Washington, SJNAHS
Dr Sanjiv Lewin SJNAHS
Dr K Karthikeyan, Independent Consultant
Dr Manoharan, Independent Consultant
Dr Savitha Kamalesh, SJNAHS
Ms N Gayathri, SJNAHS
Dr Reynold Washington, KHPT/UoM
Dr Lisa Avery, UoM
Dr B M Ramesh, KHPT/UoM
MrArin Kar, KHPT
Mohan H L, KHPT/UoM
Dr Swaroop N, KHPT
Dr Krishnamurthy, KHPT/UoM
Skilled birth attendance care during labour, delivery and postnatal periods at 24/7 Primary Health Centres
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About the Manual
The Sukshema project aims at providing technical support to National Rural Health Mission of Karnataka
to improve the maternal, newborn and child health (MNCH) outcomes in Karnataka with a focus on eight
districts of northern Karnataka. As a part of the project, several interventions are implemented at facility,
community and health systems level to improve the availability, accessibility, quality, utilization and
coverage of critical MNCH services. One of the interventions is on-site mentoring to 24/7 PHCS to improve
the quality of delivery and postpartum care with the help of a new cadre of nurse mentors. Being a new
cadre, the project designed a training program and manuals for training this cadre. The nurse mentors are
expected to be proficient in clinical skills related to delivery and postpartum care and also have the right
attitudes and abilities to provide mentorship to the PHC staff. They will be responsible for onsite, on the job
coaching and facilitating change in provider practices that will ensure better quality care for women and
babies. The purpose of this manual is to guide the MNCH mentors of the Sukshema project in how to assist
health care providers at primary health care centres (PHCs) to improve the quality of labour and delivery,
postpartum and newborn care services.This manual is used by participants during initial training and also
as a guide during mentoring activitiesHn the field.
This manual is divided into three volumes.
Volume 1 - Volume 1 has two sections.
Section A - Approaches to Improving Quality of MNCH Services in Primary Health Centers
This section introduces the context of MNCH mentoring intervention in the Sukshema Project, Karnataka,
principles of quality improvement, Sukshema's quality improvement approach and tools, and their use at
various levels, qualities of an MNCH mentor, and mentor responsibilities.
Section B - PHC Systems Strengthening
This section contains technical information related to systems strengthening in PHCs and covers infection
prevention, referral system strengthening and supply chain management.
Volume I appendix include various tools and reporting formats that the MNCH mentors use to plan,
implement and report on their PHC visit activities.
Volume 2 - Skilled Birth Attendance during Labour, Delivery and Postnatal Periods at 24/7 PHCs
This volume contains information related to clinical knowledge and skills required to provide quality
care during labour, delivery and postnatal period at 24/7 primary health centres. The section covers both
provision of routine delivery and postnatal care as well as identification, management and referral of most
common maternal complications during these periods.
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Mentors' Manual Volume 2
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About the Manual
Volume 3 - Essential Newborn Care at 24/7 PHCs
This volume contains information related to clinical knowledge and skills required to provide quality care
during the early neonatal period at primary health centres. The section covers both provision of routine
newborn care as well as identification, management and referral of most common newborn complications.
Though this manual is divided into three volumes for the convenience of readers, each volume has links and
cross references with the others. It is highly recommended that the mentors consult all three volumes when
preparing for a mentoring visit and also have them available for ready reference during a mentoring visit.
In the first volume of the manual we introduce the A.M.M.A approach to quality improvement. A.M.M.A approach
refers to assess (A), manage (M), measure (M) and advocate (A) for continuous quality improvement and has
at its core, the key principles of client and provider rights, self assessment and team building, and mentoring.
This approach can be used at several levels to improve PHC linkages with the community, to address PHC level
problems, to improve individual provider's knowledge and skills and to improve PHC linkages with the wider
health system.
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Skilled birth attendance care during labour, delivery and postnatal periods at 24/7 Primary Health Centres
Abbreviations
ABO
Blood groups A, B, O
coc
Combined oral contraceptive
A.M.M.A
Assessing and diagnosing,
CPD
Cephalopelvic disproportion
managing, measuring and
CVS
Cardiovascular system
DBF
Direct breast feeding
DDK
Disposable delivery kit
DHO
District health officer
advocating
Active management of the third
AMTSL
stage of labour
ANC
Antenatal care
ANM
Auxiliary nurse midwife
APH
Antepartum hemorrhage
DNS
Dextrose normal saline
ASHA
Accredited social health activist
DPS
District programme specialist
ART
Antiretroviral therapy
EBM
Expressed breast milk
AWW
Anganwadi worker
ECP
Emergency contraceptive pill
AZT
Zidovudine
EDD
Expected date of delivery
BCC
Behaviour change communication
FEFO
First expired, first out
BEmONC
Basic emergency obstetric and
FHR
Fetal heart rate
neonatal care
FHS
Fetal heart sound
BM
Breast milk
FIFO
First in, first out
BMV
Bag and mask ventilation
FRU
First referral unit
BPL
Below poverty line
FS
Female sterilisation
CBO
Community-based organisation
Gol
Government of India
CCT
Controlled cord traction
H/O
History of
CEmONC
Comprehensive emergency
Hb
Haemoglobin
obstetric and neonatal care
HBV
Hepatitis B virus
CHC
Community health centre
HCP
Health care providers
CBMWTF
Common bio-medical waste
Hg
Mercury
treatment facilities
HBsAg
Hepatitis B surface antigen
Chief medical officer
HCG
Human chorionic gonadotrophin
DMPA
CMO
vm
Mentors' Manual Volume 2
Depot medroxyprogesterone
acetate
Abbreviations
Development
HIV
Human immuno deficiency virus
HLD
High level disinfection
MPHW
Multipurpose health worker
HMIS
Health management information
MRP
Manual removal of placenta
MTP
Medical termination of pregnancy
MVA
Manual vacuum aspiration
NFHS
National Family Health Survey
NGO
Non-governmental organisation
NRHM
National Rural Health Mission
NS
Normal saline
NSSK
Navjaat Shishu Suraksha
system
HR
Heart rate
H2O
Water
IM
Intramuscular
Inj
Injection
IV
Intravenous
ICTC
Integrated counselling and testing
centre
IFA
Iron and folic acid (supplements)
IMNCI
Integrated management of
Karyakram
NSV
No-scalpel vasectomy
neonatal and childhood illness
PEP
Post-exposure prophylaxis
IUCD
Intrauterine contraceptive device
PHC
Primary health centre
IUD
Intrauterine death
PIH
Pregnancy induced hypertension
IUGR
Intrauterine growth retardation
PIP
Project implementation plan
JSY
Janani Suraksha Yojana
PNC
Postnatal check-up
JHFA
Junior health female assistant
POC
Products of conception
KMC
Kangaroo mother care
PPE
Personal protective equipment
LAM
Lactational amenorrhea method
PPH
Postpartum hemorrhage
LBW
Low birth weight
PPTCT
Prevention of parent-to-child
LHV
Lady health visitor
LMP
Last menstrual period
PPV
Positive pressure ventilation
MgSO4
Magnesium sulfate
PRI
Panchayati Raj Institution
MM
MNCH mentor
PROM
Premature or pre-labour rupture of
MMR
Maternal mortality ratio
MNCH
Maternal neonatal and child health
MO
Medical officer
MoHFW
Ministry of Health and Family
transmission
membranes
MoWCD
P/A
Per abdomen
P/S
Per speculum
P/V
Per vaginum
Welfare
QI
Quality improvement
Ministry of Women and Child
RCH
Reproductive and child health
Skilled birth attendance care during labour, delivery and postnatal periods at 24/7 Primary Health Centres
Skilled birth attendance care during labour, delivery and postnatal periods at 24/7 Primary Health Centres
RDK
Rapid diagnostic kit
STI
Sexually transmitted infection
Rh
Rhesus factor
TBA
Traditional birth attendant
RL
Ringer lactate
TT
Tetanus toxoid
RPR
Rapid plasma reagin
UTI
Urinary tract infection
RR
Respiratory rate
VDRL
RTI
Reproductive tract infection
Venereal Disease Research
Laboratory
SBA
Skilled birth attendant
VHND
Village health and nutrition day
SC
Sub-centre
WBC
White blood cell
SDM
Standard days method
WHO
World Health Organization
SN
Staff nurse
3TC
Lamivudine
Units of measurement
Kilocalories- to measure energy
produced
At the rate of - to measure speed I KCal
%
Percent - to compare anything to
100‘
I Kg
*
Kilogram - to rrieasure weight
°C
Degree Celsius - for temperature
L
Litre to measure volume
cc
Cubic centimetre - to measure
volume
lb
Pound to measure pressure
mcg
Microgram to measure weight
mg
Milligram to measure weight
cm
Centimetre - to measure length
dl
Decilitre - to measure volume
min
Minute
°F
Degree Fahrenheit - for
temperature
ml
Millilitre to measure volume
Gram - to measure weight
mm
Millimetre to measure length
gm
hrs
Hours - to measure time
mmHg
Millimetre of mercury to measure
BP
IU
International units - to measure
dose
secs
Seconds
U
Units to measure dose
Mentors' Manual Volume 2
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Glossary of Terminology
Abortion: Termination of pregnancy by the removal or expulsion of a foetus or embryo from the uterus
before 20 weeks of pregnancy
Abscess: A localized collection of pus in any part of the body, with pain and redness.
Amniotic fluid: Fluid present in the uterus during pregnancy which protects the fetal inside
Amnionitis: Infection of the protective lining around the baby (amnion or inner lining);
occurs in PROM
Anaemia: Condition caused by low hemoglobin in blood
ANC: Check up done during pregnancy to determine the condition of the woman and fetus
APGAR: The APGAR score indicates the newborn's well-being. It will be calculated at 1 minute and at
5 minutes after birth. An APGAR score of more than 7 is considered satisfactory. Less than 7 APGAR babies
need referral to a higher centre for further management
.
APH: Bleeding in pregnancy (before delivery)
Asphyxia: Condition in a newborn due to severely deficient supply of oxygen to the body when the baby
is unable to breathe normally
Atonic: Lack of muscle tone; loose or soft
Assisted deliveries: Vaginal delivery when the baby's delivery has to be assisted/helped out by using
forceps or vacuum extraction applied to the baby's head
Blurred vision: Unclear or hazy vision, associated with high blood pressure, weakness
Breech presentation: When the buttocks of the fetus are in the lower area of the uterus
Chorioamnionitis: Infection of the protective lining around the fetus (amnion or inner lining and
chorion or outer lining); occurs in premature rupture of membranes (PROM)
Clammy skin: When the skin is cool, moist, and pale. Sign of emergency such as shock, dehydration
CRD: Size or space of pelvis is narrow and does not allow baby to pass through
CVS: System related to heart and circulatory system
Diastolic blood pressure: Lower reading of blood pressure
Depressed/depression: Sadness, no interest in surroundings; may be seen in postnatal period
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DMPA: Injectable contraceptive whose action lasts for 6 months
ECP: To be taken by a woman within 72 hours of unprotected, unplanned sexual contact to prevent a
pregnancy
Effacement: Thinning of cervix at the time of labour
Endometritis: Infection of uterus; after PROM, repeated per vaginal (PV examination, unsterile conditions,
after abortion/ MTP done in unsterile conditions
Engorgement: Filling up/ swelling
Flank pain: Pain in the side of the abdomen below the ribs
Fluctuant: Moving
Floppy: Poor muscle tone, limp
Fetal: Developing unborn baby inside the uterus
Fetal distress: Condition when the fetus is having some problem inside the uterus; detected by abnormal
heart rate (FHR more than 160/min or less than 120/min), or irregular FHR
Fundal height: Height of the uterus which increases with pregnancy and decreases after delivery;
measuring the upper border of the uterus and comparing with the standard in weeks of pregnancy gives
the approximate duration of pregnancy
Gestation: Pregnancy / the period of development of the fetus in the uterus from conception until birth
Gestational age: Age of an embryo or fetus; calculated in weeks
Gravidity/gravid: The number of times the woman has been pregnant
Icterus: Jaundice or yellowish discolouration of sclera (white part of eye) in adult or skin in newborn
Infant: Baby from one month after birth to one year of age
IUGR: Inadequate/ slow growth of a fetus inside the uterus
Jerky movement: Fast movements which are not controlled and that have no purpose. Seen in fits
KMC: Care given to small baby by placing over the chest of mother/parent to provide extra warmth to the
baby
LAM: Used as a traditional temporary method of contraception, when a woman does not have her monthly
periods due to breast feeding
Latent: Developing or present but not visible
LBW: When the baby weight is below 2500gms (standard weight)
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Glossary of Terminology
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Lump: A localised swelling; may be hard or soft
Lochia: Discharge from the vagina from delivery up to a week
Liquor: Same as amniotic fluid
LMP: First day of last menstrual period a woman had before pregnancy, used to calculate EDD
Madilu kit: This is a postnatal kit given to mothers after delivery under a government scheme for postnatal
care of mother and baby
Mastitis: Infection of breast; seen as pain and redness
Meconium: Yellow or green coloured stools passed by the fetal inside uterus or by newborn at birth
MRP: Done by removing the placenta by hand in condition of retained placenta
Murmur: An abnormal sound of the heart
MVA: Method of performing MTP where suction is created by a manual pump to remove contents in
uterus
Misoprostol: Drug used to cause contraction of uterus and thereby prevent or treat postpartum
hemorrhage; available as tablets of 200mcg; not given to women with asthma
Magnesium sulfate: An anti-convulsant drug used for preventing/treating eclampsia/severe
pre eclampsia without causing sedation in mother or baby
Monitoring: Observe and check the progress or quality over a period of time
Nasal flaring: An increase in nostril size due to any difficulty in breathing
Newborn: A recently born baby
Obstetric: Related to pregnancy
Obstructed: Blocked; unable to come out
Oedema: Swelling due to accumulation of water
Outcome: End result
Pallor: Lack of colour especially in the face; seen in anaemia and long standing diseases
Parity/Para: Total number of deliveries and abortions a woman has had till present pregnancy
Pelvis: Cavity formed by joining together of the two hip bones and sacrum; contains, protects, and
supports the intestines, bladder, and internal reproductive organs
Perineum: Area around vagina and the anus in females
XIII xSkilled birth attendance care during labour, delivery and postnatal periods at 24/7 Primary Health Centres
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PIH: Increased blood pressure (more than 140/90 mmHg) without proteinuria in a woman after 20 weeks
gestation
Preterm: Pregnancy less than 37 completed weeks gestation
Pre-referral management: Activities carried out to stabilise the complicated cases before referring to
a higher centre
Presentation: That part of the fetal lying over the pelvic inlet which would be first to come out at delivery
P/S: Using the speculum to view the vagina and cervix
P/V: Vaginal examination
Prolonged: Long duration/delayed
PROM: Rupture of membranes (bag of waters) before labour has begun; can be before 37weeks premature or before delivery - term or mature
Puerperal: The period immediately after delivery to 42 days
Purulent: Containing pus
Pustule: A small boil over skin filled with pus; a pimple
Retained: To hold in a particular place; not coming out
RPR: A newer blood test to screen routinely for syphilis in pregnant women
RR: Rate of breathing in one minute
Respiratory distress: Condition in which patients are not able to breathe properly and get enough
oxygen
SBA: Person (doctor, nurse, ANM) trained in pregnancy, delivery, postnatal and newborn care
SDM: Used as a traditional temporary method of contraception where a woman tracks the days of her
menstrual cycle and avoids unprotected sexual contact on fertile days of the cycle
Sepsis: Condition where infection from any site spreads throughout the body
Mentors' Manual Volume 2
Glossary of Terminology
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Seizures: Convulsions, fits
Spontaneous: Without any effort or natural
Sterilization: A procedure to make free from live bacteria, virus or other microorganisms, used for
cleaning needles and surgical instruments
Stillbirth: Birth of a dead fetus any time after the completion of 20 weeks of gestation.
Syphilis: A sexually transmitted disease which in pregnancy may cause congenital defects in the fetus
Systolic blood pressure: The upper level of blood pressure
Tender/tenderness: Pain felt if touched
Term: State of pregnancy which has completed 37 weeks
Transverse: Lying across
Traction: Pulling force
Tubectomy: It is a female sterilization procedure where a part of the fallopian tubes is cut. It is a
permanent method of female sterilization
Umbilicus: A scar where an umbilical cord was attached
Unconsciousness: Person not responding to calls, stimulus
Uterine massage: Gently rubbing the uterus after the delivery of placenta to help the uterus contract
and become hard
Uterine tone: Tightness of uterine muscles
Vasectomy: A surgical procedure performed on males in which the vas deferens (male tubes) are cut. It
is a permanent method of male sterilization
VDRL: Blood test done routinely for syphilis in pregnant women; similar to RPR test
Vertex: Normal presentation of the fetus in which the head lies at the opening of the uterus
Voiding: Emptying the urinary bladder
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Maternal Health Situation In
Northern Karnataka
1.1 Introduction
Maternal and neonatal child health services have long been seen as inseparable partners. Though clinical
interventions needed to avoid maternal and neonatal deaths and disability are well established, it is now
known that these interventions require a functioning health system to have the desired impact at the
population level. Levels of maternal and neonatal mortality are thus regarded as sensitive indicators of
the entire health system and can therefore be used to monitor progress. What is also clear is that maternal
and neonatal mortality continue to remain particularly high in northern Karnataka compared to southern
Karnataka as well as the neighbouring south Indian states.
1.2 Definitions
We define maternal conditions as those events occurring from conception to 42 days postpartum.
Within this period, two broad categories of illnesses can be identified: those arising specifically from
pregnancy and parturition (direct obstetric complications), and those worsened by pregnancy (indirect
obstetric complications). The focus of this manual is on four direct obstetric complications - hemorrhage,
hypertensive disorders of pregnancy, sepsis and prolonged/obstructed labour.
1.3 Understanding the Maternal Health Situation in Karnataka
To better understand the maternal health situation warranting action in northern Karnataka, we try to
answer the following four questions.
What are the causes of maternal deaths?
Common causes of maternal deaths are shown in Figure 1.1. Four of these conditions also called direct
causes, (hemorrhage, infections/sepsis, obstructed labour and hypertensive disorders of pregnancy) are
responsible for nearly two-thirds (60%) of maternal deaths.
Indirect causes
Please note that
25%
Other direct causes
18%
Unsafe abortion
(hemorrhage)
A-13%
Obstructed labour
12%
/
Infections
15% —
( \
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/
Eclampsia
8%
Figure 1.1 Causes of maternal deaths
n_____
Severe bleeding
Mentors' Manual Volume 2
four direct obstetric
complications contribute
to approximately 60%
of avoidable maternal
mortality
Chapter 1
■ill
lili
When do most maternal deaths occur?
The most extreme negative outcome, death of both the woman and the baby, is highly concentrated
around the time of delivery, from the onset of labour to two days postnatal (see Figure 1.2). Two-thirds of
maternal deaths (77%) occur in this time-window.
Adolescence and
before pregnancy
Pregnacy
Childhood
Window of opportunity
Weeks
Days
Condition
1
% of mternal deaths*
2
3
60% 17%
4
5
6
2
7
3
4
5
6
4%
13%
Figure 1.2: Timing of maternal deaths
What is the urgency associated with these deaths?
Two important characteristics of these deaths are:
❖ Unpredictability (cannot foresee or predict in most cases) of these maternal conditions
❖ The initial clinical presentation of some conditions could be severe, with rapid escalation (worsening) to
a life-threatening state.
This means that the average duration from onset until death is short if these conditions become serious
(Table 1.1). Thus it is important that these conditions are identified as soon as possible and action is taken
immediately to reduce the chance of a woman or neonate dying.
Table 1.1: Time to act for common direct obstetric conditions
Average duration until death if condition very
Maternal Condition
serious
1. Hemorrhage
antepartum
12 hrs
2
hrs
2. PIH/pre-eclampsia/eclampsia
2
days
3. Obstructed labour
3
days
4. Sepsis
6
days
❖ postnatal
Further, it is also clear that maternal mortality continues to remain particularly high in Karnataka
compared to the neighbouring south Indian states such as Tamil Nadu, Andra Pradesh, Kerala
(Figure 1.3). Several background socioeconomic, historic and cultural reasons exist for this, but
the poor conditions of the health centres in the northern districts of Karnataka are also one of
the contributory reasons.
2^
Skilled birth attendance care during labour, delivery and postnatal periods at 24/7 Primary Health Centres
Skilled birth attendance care during labour, delivery and postnatal periods at 24/7 Primary Health Centres
Karnataka lagging
behind other south
Indian states
IIMI
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TRil
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Figure 1.3: Maternal Mortality state wise in India
What does this mean for your district?
See the estimated number of births and maternal deaths in a 12-month period in each of your districts
(Table 1.2). About one fifth of these births occur in primary health centres (PHCs).Thus as nurse mentors
you can help to prevent complications and death by maintaining quality of care in the important window
of opportunity period (that means during labour, delivery and early postnatal and neonatal period).This
could include simple actions such as to follow infection control guidelines; identify complications, start
initial management and refer such women; manage normal labour, delivery and early postnatal effectively.
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Table 1.2: Project Sukshema districts with their population and estimated number of live-births
and maternal deaths per year
Population (year 2011)
Maternal deaths per year*
Live-births*
Bagalkot
2476587
163
57900
Bellary
1848941
121
43300
Bidar
1678599
110
39200
Bijapur
2134790
140
50000
Gulbarga
2522079
166
59000
Koppal
1370023
90
32100
Raichur
1897372
.. 125
44400
Yadgir
1148788
76
26800
District
* assuming crude birth rate = 23.4/1000 and maternal mortality rate =280/100,000 in northern Karnataka
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12 Initial Assessment at Admission
Learning Objectives
At the end of this chapter you will
❖
Recall the importance of doing a complete initial assessment of pregnant women after 20 weeks of
gestation, presenting to the PHC
❖
List and describe the relevance of the components of a good initial assessment
❖
Demonstrate how to do a comprehensive assessment
❖
Demonstrate documentation in the case sheet, the details of complete initial assessment of the
woman in labour.
❖
Demonstrate mentoring skills for doing a complete initial assessment of the pregnant woman
2.1 Introduction
A woman who is more than 20 weeks pregnant must have an initial assessment that includes a targeted
history and examination to provide comprehensive care. This could help identify normal or abnormal
pregnancies. It could also alert the nurse of women with increased risk for complications. If the pregnancy
is abnormal and/or if a complication is present, initial assessment could alert the nurse to take immediate
action so that the women condition is stabilized before referral to a higher level centre for further treatment.
2.2 Components of Initial Assessment
History
❖
Background information
❖
Presenting complaints, danger signs
❖
Menstrual and obstetric history
❖
Previous obstetric history
❖ Other medical/surgical history
Previous Investigations
Examination
❖ General examination
♦♦♦ Abdominal examination
❖
Pelvic examination
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Diagnosis (Overall initial assessment)
2.3 Importance of Different Components of Initial Assessment
Background information
Background information could help to build rapport, provide important socio-demographic infor
mation and facilitate referral.
❖ Age is taken because women who are less than 18 or more than 35 years of age have a higher risk of
pregnancy-related complications.
❖ Below poverty line (BPL) status is taken so that benefits available (madilu kit, financial aid for
institutional delivery, transport money for emergency if ambulance 108 is not available) are received by
the woman. This is very important for poor families especially in case of referral.
❖ Date and time are important to record in order to track quality of care, events, complications
and referral.
Presenting complaints, danger signs
Presenting complaints could alert the nurse to danger signs and help differentiate normal from abnormal.
❖ Abdominalpa/nwith a contraction is normal.Too much abdominal pain or pain between contractions
could be a symptom of ruptured uterus / abruptio placenta (see complication case sheet A) uterine
infection (see complication case sheet D) or a complication related to PIN (see complication case sheet
B).This is a flag to check vital signs and perform an abdominal examination to help determine the
cause or check for bleeding per vagina (see complication case sheet A).
❖ Bleeding per vagina could be bloody show (mucus with blood in it), but if it is too much it is a sign
of hemorrhage. If placental location is not known per vaginal (PV) exam must NOT be done. It is a flag
to check for change in vitals (low BP, rapid and thin pulse), abdominal tenderness and pain between
contractions. It also is a flag for immediate referral after initial management so that the woman does
not go into shock(see complication case sheet C).
❖ Decreased or absent feta! movement can indicate fetal distress or an intra-uterine death. This is a
flag to ensure that the fetal heart rate is checked, initiate initial management and refer urgently (see
complication case sheet H).
❖ Difficulty passing urine may be a complication of pregnancy induced hypertension (PIH), kidney
disease or due to obstructed labour or urinary tract infections. It is important to check for a full bladder
by examining the lower abdomen.
❖ Fevehs a symptom of infection. If present, it is a reminder to check temperature and look for a focus
of infection (see complication case sheet D).
❖ Foul discharge per vagina is a sign of uterine infection (chorioamnionitis).This is a flag to check the
vital signs and perform an abdominal exam for uterine tenderness (see complication case sheet D).
❖ Headache, blurred vision, vomiting are symptoms of PIH/pre-eclampsia. Seizures/ fits are signs of
eclampsia. These complaints should serve as a red flag to check the blood pressure to see if it is normal
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or not and test urine for protein (see complication case sheet B).
❖ Palpitations, severe tiredness, breathlessness at rest or on mild activity could alert of the chance
of severe anemia, or cardiac disease.These symptoms are flags to ensure that the pulse, blood pressure,
pallor, lungs and heart, as well as previous investigations for hemoglobin (anemia) and are checked
(use complication case sheet H).
❖ Watery discharge before term (37 completed weeks of gestation) indicates preterm rupture of
membranes. This is a flag to check the temperature and check the colour of liquor. It is important to
check if woman has labour pains (see complication case sheet E).
Menstrual and obstetric history
The menstrual and obstetric history provides important information to check if this pregnancy may be
high or low risk and to find out gestational age.
❖ Gravida and parity indicates how many times a woman has been pregnant (gravida) and how many
times she has given birth after 28 weeks, irrespective of outcome (parity). Women with more than four
deliveries (grand multiparity, P4) are at an increased risk of having complications in pregnancy, labour
and delivery or a woman with no live baby could flag risk of complication.
❖ Last day of menses, length and regularity of menstrual cycle are needed to calculate the estimated
due date of the baby. If the menstrual cycle of a woman is not regular this is a flag that calculation of
gestational age will riot be accurate.
❖ Gestational age will help to know if the baby is preterm (less than 37 weeks), term (37-40 weeks
gestation) or post-term (greater than 41 weeks). A woman who comes with preterm or post term labour
could be a flag to check if the woman has a pregnancy complication (for example PIH, twin pregnancy
if preterm; diabetes if post term) and if needed to refer.
❖ Type of gestation is important since multiple pregnancies (twins/triplets) are at greater risk of
complications in pregnancy, labour and delivery and must be referred to a higher health care centre
(First referral units /district hospital).
Previous obstetric history
A woman's past history of pregnancies and deliveries also provides information to decide if she needs
additional treatment, care or referral to a higher centre for the present pregnancy.
❖ Year of delivery could help to know about the birth spacing/interval. Women who have a space
of less than 36 months (3years) between children have more chances of delivering a preterm and
low birth-weight baby. These babies are at increased risk of infant mortality. An interval of less than
24 months (2 years) from the previous pregnancy can also increase the chance of maternal anemia.
♦♦♦ Mode of delivery could be important for management. For example if delivery was by cesarean
section then this information shows that the woman should be referred to a FRU as there is a chance of
increased risk of complications such as uterine rupture during labour.
❖ Place ofdelivery could help to know where the woman had her deliverythe previous time. This could
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help to know if women were prepared and had planned for delivery (birth planning).
❖ Women with complications'^ previous pregnancies, labour, delivery and postnatally may have the same
complication again. Knowing about past complication could be a flag to watch for and be prepared for the
same complication in the present pregnancy. It may also be a flag to initiate preventive screening or treatment
in the current pregnancy. For example a woman with pregnancy induced hypertension (RIH) in the previous
pregnancy has more chance of developing RIH for the present pregnancy.
❖ Women with adverse feta! outcomes (stillbirth, neonatal death) may also have the more risk
for adverse outcomes with this pregnancy. This can also cause anxiety and stress during the current
pregnancy. Knowing this history could flag to provide reassurance for the woman. In addition the
woman and the newborn must be monitored closely for danger signs.
Other history
Pre-existing medical or surgical conditions can increase a woman's risk of developing a complication in her
present pregnancy. All pre-existing conditions are red flags for referral to an FRU for further management
and ongoing care.
❖ Diabetes can lead to maternal (high and low blood sugars, infection, other medical problems) and fetal
complications (congenital defects/anomalies, large babies, stillbirths, neonatal complications) including
obstructed labour and increased risk for instrumental vaginal delivery or cesarean section.
❖ Pre-existing anemia can lead to more severe anemia in pregnancy that could cause heart failure, as
well as place the mother at increased risk of death from severe bleeding postnatally.
❖ Pre-existing cardiac disease could become worse in pregnancy or labour and delivery. This can
result in shock, heart failure or irregular heart rates and heart attacks.
❖ Pre-existing hypertension increases the risk of developing hypertensive diseases of pregnancy
(RIH, pre-eclampsia, eclampsia). Plus the chance that the fetus growth could be affected is high.
❖ Previous uterine surgeries increase the chance for uterine rupture.
❖ Allergies, Medication: This information could inform if there are any medications being taken for
current or pre-existing medical conditions, if the woman has received recommended medications in the
present pregnancy and if there are any medications that cause an allergic reaction in the woman.
Allergies show if there are any medications that need to be avoided in the woman This is important
to know before giving any medication especially antibiotics.
Tetanus vaccination prevents neonatal and maternal tetanus. If not received this is a red flag to
make sure that it is given.
Iron and Folic Add (IFA) helps increase iron and hemoglobin which helps prevent anemia and
the complications of anemia. If it is not being taken this is a red flag to ensure that it is given.
Previous/Current Investigations
These investigations are important because they screen for conditions in pregnancy that if found
could be treated, leading to decreased complications for the woman and unborn baby (fetus).
♦♦♦ Hemoglobin screening detects anemia, which increases both maternal and fetal complications.
8 >
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Treatment with IFA or blood (depending on severity) could be given to prevent this. Levels less than
7 gm/dl serve as a red flag to refer to a higher centre for care. Levels between 7 and 11 gm/dl on
previous tests serve as a flag to repeat the test to recheck the levels and to be alert for PPH.
❖ Blood group and type (ABO and Rh) screens for Rh disease, which helps prevent Rh isoimmunization.
If the blood group is known it could be of great help if there is bleeding, since blood transfusion could
be started as soon as possible, when required.
❖ Hepatitis B screening detects hepatitis infection, which also is easily transmitted to the infant. This
could be prevented with immunoglobulin and Hepatitis B vaccination at birth.
❖ HiVscreening detects HIV infection. There is a high risk of vertical transmission to the newborn /
infant from woman during delivery or breast feeding. Prevention of maternal transmission of HIV to
the baby (PMTCT) could be reduced greatly with use of antiretrovirals during pregnancy, labour and
postnatally; and by counselling on breast feeding.
❖ Syphilis screening (RPR/VDRL) detects syphilis infection which carries a high risk of congenital
syphilis for the newborn. Treatment with penicillin could be given to prevent this.
❖ Oral glucose tolerance testsate used to screen for development of gestational diabetes. This is done
only if the woman has a history of diabetes or is at risk for developing diabetes. Gestational diabetes
could increase maternal and fetal complications in some women. If positive it is a flag to refer to a
higher centre for care.
❖ Dipping the urine for protein screens for proteinuria is routinely done to rule out pre-eclampsia
or eclampsia. It helps know the degree of proteinuria, which is used to determine the severity of
pre-eclampsia. If present it should be a flag to check for elevated blood pressure.
❖ Screening the urine for presence of infection by doing a routine urine microscopy would help
show if there is a urinary tract infection or kidney infection (pyelonephritis). Infection could increase
the risk of preterm labour. If present this is a flag to check vital signs.
❖ Ultrasounds used to assess gestational age, single/ multiple gestation, position of placenta, congenital
anomalies. Important findings should be recorded, such as placental location in the case sheet.
If tests for Hb or screening for HIV, Hepatitis B or syphilis or urine protein have not been done this is a flag
to make sure they are ordered and done at the present visit. If tests are positive /abnormal this should serve
as a flag to initiate referral to a higher centre for care, including initial stabilizing treatment if indicated
(per the case sheet H).
Examination
The physical examination provides information on physical findings that could help to arrive at a
diagnosis and determine if there are any concerns in the pregnancy or labour (normal versus abnormal).
❖ Genera! Examination
The general examination could provide information on the overall well being and health of the
pregnant woman.
Weight shows if there is any problems about the nutritional status, or if weight gain is good
enough to maintain a healthy pregnancy. If weight gain is less it could lead to newborns with less
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weight. If weight gain is more for the woman it could lead to large newborns. Poor nutrition of
woman could also be a flag for anemia, infection and chronic disease, while too much weight gain
could flag for hypertensive disorders and diabetes. Thus if weight gain is either low or too much it
should serve as a flag to look for other possible complications and refer if needed.
Heights a woman's (especially primigravida) height is less than 140cms, she could be at increased
risk of obstructed labour. She might require referral to a higher centre.
-0- Vital signs are parameters that provide extremely relevant information. The pulse could be high
in case of fever, shock (infections, blood loss) or irregular in case of heart disease. An elevated
blood pressure of greater than 140/90 mmHg confirms PIH, while a low blood pressure of less than
90/60mmHg is suggestive of shock. A high temperature, greater than 38°C indicates the presence
of infection or sepsis. Low temperatures could be seen in some cases of shock.
4- Pallor: The presence of pallor is a marker for anemia. This should serve as a flag to check if
hemoglobin testing has been done and and insert to be alert for PPH.
Generalized oedema could be a sign of hypertensive disease of pregnancy, although swelling
in the legs and feet of pregnant women is not uncommon. Only if blood pressure is greater than
140/90 mmHg it is diagnostic for hypertensive diseases.
-0- Jaundice may indicate liver disease or hemolysis of red blood cells due to a destructive process. It
can serve as a flag to make sure blood test for screening hepatitis has been done.
Listening to the breathing sounds helps rule out any infections or heart failure.
❖ Listening to the heart sounds helps rule out any cardiac disease. The finding of a soft systolic
murmur in pregnancy could be normal due to increased
flow.
❖ Abdominal Examination
The abdominal examination provides important
information about fetal growth, number of fetuses and fetal
presentation, presence of labour, as well as any previous
■
abdominal surgeries.
Measuring symphysis fundal height (usually equal
to estimated gestational age in weeks): If there is a
difference of greater or less than 3 cm it may indicate
incorrect dating of last menstrual period (LMP), multiple
gestations or growth difference. This serves as a flag to
recheck LMP or ultrasound report if available
Presentation determines if the baby is in a position
(normal position is vertex or highest point of head) that
is suitable for vaginal delivery at the PHC. Non vertex
presentation at term or in labour is a flag for referral to a
higher centre.
Figure 2.1: Presentation
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Skilled birth attendance care during labour, delivery and postnatal periods at 24/7 Primary Health Centres
Palpating the uterus helps determine if the woman is in labour (regular, frequent contractions), has
an intra-uterine infection or abruption (generalized very tender uterus) or possible uterine rupture
(localized tenderness, especially over previous scar if present). Any abnormality must be referred.
Examining the abdomen for the presence of a previous surgical scar will provide important
information for any contraindication for normal labour (e.g classical cesarean section). If prior
cesarean section scar is present this should serve as a flag to refer to a higher centre for care in labour.
4- Measuring the fetal heart rate is
important to check if the fetus is alive and
that the heart rate is normal. When heart
rate is between 110-160 beats/minute it
means there is no sign of fetal distress. No
fetal heart or abnormal fetal heart rate (less
than 100 or more than 160 beats/minute) is
a flag to refer to a higher centre.
❖ Vagina! Examination
The pelvic examination provides important
Figure 2.2: Causes ofAPH
information about labour, progress of labour,
complications of pregnancy and fetal well
being. The following must be checked for during a vaginal examination:
Bleeding from the vagina could be a sign of bloody show (presence of blood stained mucus),
placental abruption (separation of placenta), or placenta previa (placenta is attached to lower part
of uterus near the cervix). It is a flag to not perform a pelvic examination if the placental location is
not known. It is also a flag to check vital signs including fetal heart rate.
Cervical dilation (opening of the cervix) and effacement (thinning) helps to know if the woman
is in active labour (3-4 cm, 80-90% effaced) and if the labour is progressing normally (rate of
cervical change).
Discharge (watery) from the vagina is a sign of rupture of membranes. It is a flag to check the
gestational age and if the woman is in labour or not.
4 Discharge (purulent) indicates intra-uterine infection /chorioamnionitis (inflammation of fetal
membranes due to bacteria). It is a flag to check vital signs including fetal heart rate.
-0- Green stained fluid from the vagina (meconium) could be a sign of fetal distress. It is important
to think about preventing meconium aspiration at time of delivery.
Presenting part helps to know the position of the fetus and whether it is suitable for vaginal
delivery at the PNC. If vertex is not the presenting part and the woman is not in active labour it is
a flag to refer to a higher centre for care.
Station describes where the fetal head is in relation to the woman's ischial spines (above or below)
and also tells us if descent of the head is happening normally.
0 Adequacy of the pelvis can help to know if there is risk of obstructed labour. In an adequate
pelvis, with strong contractions and a normal size fetus the risk is low.
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Recording the time of pelvic examination is important in order to know if labour is
progressing appropriately.
Diagnosis (Overall initial assessment)
The final diagnosis determines the next steps of management and care, including need for admission or
initial stabilization and referral. It is arrived at by combining the history (especially presenting complaints)
and physical exam findings. If there is complications present this is a flag to move to the complication case
sheets for further management prior to referral.
2.4 Requirements to Perform Initial Assessment of Woman in Labour
Equipments and supplies
Ensure that the following equipment is available at the PHC and in working condition:
❖ Examination table and stepping stool
❖ Blood pressure apparatus
❖ Stethoscope
❖ Thermometer
❖ Fetoscope
❖ Measuring tape, watch with seconds hand
❖ Case sheet with partograph
❖ Sterile gloves, sterile/boiled cotton swabs for perineal
care
❖ Antiseptic lotion and 0.5% bleach in a plastic container
Clinical skills
History taking
Use the case sheet to collect the complete history of the woman
when she comes to PHC with labour pains.
General examination
Figure 2.3: Checking radial or brachial pulse
Maintain the woman's privacy during the entire process.
Wash hands thoroughly with soap and water, air dry them before starting.
Measuring vital parameters
Measuring PULSE
1.
Palpate (feel) the woman's radial pulse by placing the finger tips of 3 fingers on her wrist, below her
thumb.
2.
Press against the radial artery and then slowly release the pressure until you can feel the pulse.
3.
Count the beats for a full minute.
Skilled birth attendance care during labour, delivery and postnatal periods at 24/7 Primary Health Centres
Skilled birth attendance care during labour, delivery and postnatal periods at 24/7 Primary Health Centres
Measuring MOO£)M£SS(//?£(IN EMERGENCIES, BP HAS TO BE MEASURED RAPIDLY)
1. Ask the woman to sit or lie down comfortably and relax. If the woman has come walking, let her rest for
5-10 minutes before checking her BP. In an emergency skip this step
2. Place the BP instrument on a flat surface, at the same level with the woman's heart.
3. Ensure that the pointer on the dial or scale is at zero. If not, adjust it by rotating the knob attached to
the dial.
4. Keep the dial/ manometer at the same level as the examiner's eyes.
5. Remove all clothing from the upper arm. Wrap the cuff around the upper arm and secure it. The lower
border of the cuff should be about 2.5 cm (2 fingers) above the hollow of the elbow. Ensure that the cuff
is neither too tight (cannot slip one finger under the cuff) nor too loose (can slip more than three fingers
under the tied cuff).
Palpatory method
1. Feel for the pulse over the wrist (radial pulse) of the arm to which the cuff is tied with the left hand.
2. Tighten with the right hand, the screw of the rubber bulb and squeeze the bulb repeatedly to inflate the
cuff until the pulse is not felt.
3. Note the manometer reading at the level where the pulse is not felt.
4. Deflate the cuff gradually till the pulse can be felt again. Note this reading on the manometer.This is the
systolic pressure.
5. Deflate the cuff by loosening the screw of the rubber bulb. Proceed to measure the BP by the
auscultatory method.
Note: The diastolic BP cannot be measured by palpatory method.
Auscultatory method
1. Put the stethoscope earpieces in the ears with it facing forwards after measuring the BP by the palpatory
method. Place the flat part (diaphragm) of the stethoscope over the brachial pulse in the hollow of the
elbow (cubital fossa) and hold it in place. It is important not to be able to hear any sound. Inflate the
cuff, so that the mercury levehncreases by 10mmHg above the level at which pulse disappeared when
checking by palpatory method.
2. Lower the pressure slowly, about 2mmHg at a time, till repetitive thumping sounds is heard.
3. Note the reading on the instrument when the first thumping sound is heard. This is the systolic pressure.
4. Continue lowering the pressure until the thumping sound first gets muffled and finally disappears.
Note the reading when the thumping sound disappears. This is the diastolic pressure.
5. Release the valve and quickly allow all the air to go out of the cuff. Remove the cuff.
6. Record the BP reading as'systolic/diastolic'in mmHg.
Measuring RESPIRATORY RATE
1. Count the respiratory rate (RR) by observing the rise and fall of the chest for 1 minute.
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Measuring TEMPERATURE
1. Clean the thermometer from bulb to tip with spirit swab and wipe dry. Shake the thermometer such
that the mercury level is below 36°C.
2. Place the bulb of the thermometer in the axilla of the woman and fold her arm across her chest for
3 minutes.
3. Remove the thermometer and note the reading in degree Celsius
4. Wipe the thermometer with spirit swab from tip to bulb end, replace in its container and store in clean
dry place.
Other aspects of general examination
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Checking for PALLOR
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1. Look for conjunctiva pallor—ask the woman to look
up and pull down the lower eyelid gently with the
index finger. Observe the colour of the inside of the
lid. It should be bright pink or red. If it is pale pink or
white, the woman has pallor.
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2. Examine the tongue. If it is white and smooth, the
woman has pallor.
3. Examine the nails. If they look white instead of the
usual pink, the woman has pallor.
Figure 2.4: Checking for edema
Checking for JAUNDICE
1. Look for yellowish discoloration of the skin and conjunctiva (upper outer quadrant) in natural light.
2. Check if discoloration is present, then refer the woman to the medical officer or higher centre.
Checking for EDEMA
1. Look for edema over the ankles and shin by pressing thumb against the bone for 5 seconds. If the
thumb leaves an impression, it indicates the presence of edema.
2. Use the scale to indicate how severe is the edema.
0 = None, +1 = Trace, +2 = Moderate, +3 = Deep, +4-Very deep
Checking the LUNGS
1. Observe if the woman has laboured breathing or gasping or wheezing. If she is not able to speak short
sentences without taking a breath, it indicates difficult respiration.
2. Use the stethoscope to listen for air entry in both lungs and additional sounds.
Checking the HEART
1. Check if heart sounds are normal on auscultation.
2. Check for the presence of any abnormal or additional sounds.
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Normal range of findings at term
y Gained approximately 9-11 kilograms during the pregnancy
J Height at least above140cms
J Pulse: 60-100/minute
s/ BP: 90-139mmHg systolic, 60-89mmHg diastolic pressure
Temperature: 37.2°C
>/ No evidence of pallor/ jaundice/ significant oedema
s/ Clear Lungs
y No abnormal heart sounds
Performing abdominal examination
Getting ready
❖ Ask the woman to empty her bladder.
❖ Give the woman a clean bottle and ask her to collect a little urine in it before emptying her bladder
completely. The urine will be required later to test for sugar and proteins.
❖ Maintain privacy and obtain the woman's verbal consent after explaining the procedure to the woman.
❖
Help the woman lie comfortably on her back, on the examination table. Ask her to loosen her clothes
and uncover her abdomen. Use pillow if available to support her back.
❖ Check the abdomen for any scars. If there is a scar, find out if it is from a caesarean section or any other
surgery check if it is vertical or transverse
<
Refer all women with a history of previous LSCS or abdominal surgery.
Assessing FUNDAL HEIGHT
1. Ask the woman to keep her legs straight. Provide privacy
2. Wash hands and see that they are warm (rub palms together) before placing on the woman's abdomen
3. See that woman lies flat on back with legs straight
4. Divide the abdomen into parts by imaginary lines.
-0- Draw an imaginary line passing through the umbilicus. This is the most important line.
■0- Divide the lower abdomen (below the umbilicus) into three parts, with two equidistant lines (spaced
equally) between the symphysis pubis and the umbilicus.
Divide the upper abdomen into three parts, again with two imaginary equidistant lines, between the
umbilicus and the xiphisternum.
-0- The approximate gestational age is based on where the fundus is palpated as shown in Figure 2.5.
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At 12th week: Just palpable above the symphysis pubis
At 16th week: At lower one-third of the distance
between the symphysis pubis and umbilicus
At 20th week: At two-thirds of the distance between
the symphysis pubis and umbilicus
At 24th week: At the level of the umbilicus
At 28th week: At lower one-third of the distance
between the umbilicus and xiphisternum
24
At 32nd week: At two-thirds of the distance between
7
the umbilicus and xiphisternum
\ V
At 36th week: At the level of the xiphisternum
At 40th week: Sinks back to the level of the 32nd week,
but the flanks are full, unlike that in the 32nd week.
Figure 2.5: Measuring fundal height
Assessing FOETAL LIE AND PRESENTATION (32 weeks onwards)
1. Ask the woman to flex her knees and relax her abdomen. Carry out the grips as given below (see Figure
2.6a and 2.6b).
2. Do a fundal palpation/grip - helps assess presentation
Place both hands on the sides of the fundus to determine which part of the fetus is occupying the
uterine fundus.
Check if the part is hard and globular (in cephalic presentation-normal finding) mass (this is fetal
head), or if it feels soft and irregular, this is the buttocks (inbreech presentation).
3. Do a lateral palpation/grip
-$• Place one hand on one side of the uterus to steady it. Palpate on the opposite side with the other
hand to differentiate limbs from the back.
* Feel for the the fetal back. It would feel like a continuous hard, flat surface on one side of the midline,
while the limbs feel like irregular small knobs on the other side.
Check to assess if there is more than one fetus.
4. Do a superficial pelvic grip - helps assess presentation
Spread right hand widely over the symphysis pubis, with the ulnar border of the hand touching
the symphysis pubis.
Try to approximate the fingers and thumb, by putting gentle but deep pressure over the lower part of
the uterus. The presenting part could be felt between the thumb and four fingers.
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Determine whether it is the head or breech (the head will feel hard and globular, and the breech
soft and irregular). If the presenting part is the head, try to move it from side to side. If it cannot be
moved, it is engaged.
Remember: Transverse lie needs referral
❖ During superficial pelvic grip if neither the head, nor the buttocks are felt, the
baby is lying transverse. This is an abnormal lie.
❖ In a transverse lie, the baby's back is felt across the abdomen and the pelvic grip
is empty.
❖ Refer the mother to a higher centre for instrumental delivery or cesarean section.
5. Do a deep pelvic grip (only in 3rd trimester) - helps assess presentation
Face the foot end of the bed to perform this grip.
Place the palms of hands on the sides of the uterus, with the fingers held close together, pointing
downwards and inwards, and palpate to recognize the presenting part.
-0- Check if the presenting part is the head (feels like a firm, round mass, which is ballotable, unless
engaged.), this manoeuvre, in experienced hands, will also be able to tell us about its flexion.
Check If the fingers diverge (move outward) below the presenting part it indicates engagement of
the presenting part. If the fingers converge (join) below the presenting part it indicates that the
presenting part has not engaged.
Instruct the woman to flex her legs slightly and to breathe deeply, if she cannot relax. Palpate in
between the deep breaths.
Feel to assess if there is more than one baby.
Figure 2.6a: Fetal lie and presentation
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pelvic grip/supc-rhcial peh’ic grip
The third maneuver must be performed gs-ntly. It helps to
determine whether the head or the breech is present at the
pelvic brim. If the head cannot be moved, it indicates that
the head is engaged. In the case of a transverse lie, the third
grip wOl be empty.
IX Second pdvk grip/deep pch k grip
about the degree of flexion of the head.
Figure 2.6b: Fetal lie and presentation
Presentation
Presentation needs to be confirmed with pelvic examination. The different
presentations (see Figure 2.1) may be
y Cephalic - most common, where the head of the baby is the presenting part
y Transverse
y Breech
y Others - Face, hand, foot, shoulder
❖ Remember a woman with cephalic presentation without any other problem
could be managed in the PNC.
❖ Check the shape of the uterus, noting if it is longer horizontally than vertically
(the latter could mean a transverse lie).
❖ Refer a woman presenting with either transverse, breech or any other
presentation.
Assessing CONTRACTIONS
1. Place hand on the upper part of the woman's
Remember:
abdomenandfeelforcontractionsoveralO-minute
period. Count the number of contractions during
that period (frequency of contractions).
<♦ Mild: If less than 20 seconds;
2. Keep hand in the same position for the entire
10-minute period and note down the duration of
the contractions in seconds.
<♦ Strong: If more than 40 seconds
<♦ Moderate: If between 20 to
40 seconds;
3. Note the duration and number of contractions in the 10minute period in the case sheet.
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Checking FETAL HEART RATE (FHR)
1. Check FHR only after 24 weeks since FHR cannot be heard before 24 weeks gestation (see Figure 2.7).
2. Place the fetoscope / bell of the stethoscope on the side of the uterus where the fetal back is felt
(fetal heart sounds are best heard midway between the umbilicus and anterior superior iliac spine in the
vertex and at the level of the umbilicus, or just above it in the breech).
3. Count the fetal heart sounds for one full minute.This is the FHR. If the woman has contractions, check the
FHR immediately after a contraction. Normal fetal heart rate is between 120 and 160 beats per minute.
4. Differentiate between the FHR with the pulsations of the uterine blood vessels. This could be done by
checking the woman's radial pulse simultaneously along with the abdominal FHR. If it is the same rate,
then recheck the location of the FHR.
5. Record all findings on the Case Sheet and discuss them with the woman.
Remember
❖ If FHR is absent or less than 120 beats per minute or more than 160 beats
per minute, it indicates fetal distress.
❖ To alert the medical officer and make arrangements for referral in this case.
(Note: ROA right occipitoanterior
LOA left occipitoanterior)
Checking FHR using a fetoscope.
Figure 2.7: Checking FHR
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Normal abdominal findings in a normal full term situation
❖ Fundal height two thirds between umbilicus and xiphoid sternum with
full flanks suggests term gestation (38-42 weeks)
❖ Breech felt as soft irregular mass at uterine fundus
❖ Back felt as a continuous hard surface on one side of midline, and limbs
felt as small round / knob like structures on the opposite side
❖ Hard round mass felt at superficial pelvic grip is the head,
cephalic presentation
❖ Presenting part not movable means it is engaged (36 weeks-primi
and term-multi)
❖ Only one hard round mass if palpated indicates a single fetus
❖ Uterus contracts at regular intervals with increasing intensity and duration
when in labour
❖ FHR is between 120 and 160 beats per minute
Pelvic examination during Labour
1 Keep the following equipment ready:
❖ Sterile/high levefdisinfection (HLD surgical gloves*
♦♦♦ Plastic apron
❖ Cotton swabs / balls (either boiled and cooled or sterile) in Savlon or Dettol
<♦ 0.5% chlorine solution for decontamination
2 Tell the woman and her support person (ASHA worker/or relative) what is going to be done. Encourage
them to ask questions. Listen to what the woman and her support person have to say.
3 Ask the woman to pass urine and then to lie down with her knees flexed and legs apart.
4 Put on a clean plastic apron.
5 Wash hands thoroughly with soap and water, dry them with a clean, dry cloth or air dry.
6 Uncover her genital area and cover or drape her to maintain privacy.
7 Wear HLD/sterile gloves on both hands.
8 Checkthe vulva for the presence of:
❖ Mucus discharge (bloody show)
❖ Excessive watery discharge
❖ Foul-smelling discharge
❖ Bleeding, clots
9 Clean the vulva from the pubis towards the anus and from the labia minora to the thighs without
bringing the swab back towards the vulval region with one gloved hand (not the examining hand),
using a swab dipped in an antiseptic solution (Dettol/Savlon).
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10. Use the thumb and forefinger of the non dominant hand (for example left hand) to part the labia majora,
so that the vaginal opening is clearly visible.
11. Insert the index and middle fingers of the examining hand into the vagina gently. (Once the
fingers are inserted, do not take them out till the examination is complete). Assess the following
❖ Cervical dilatation
❖
Cervical effacement
❖
Presence of membranes
❖
Presenting part
❖
Station of presenting part
❖
Pelvic adequacy
DO NOT proceed with PV if
bleeding or clots are present
12. Check cervical dilatation: Keep one hand on the women's lower abdomen, just above the pubic
symphysis. When the examining fingers reach the end of the vagina, turn fingers upwards so that they
come in contact with the cervix.
❖
Locate the cervical os by gently sweeping the fingers from side to side. The os will be felt as an
opening in the cervix. The os is normally situated centrally, but sometimes in early labour, it will be
far posterior (backwards).
❖
Feel the cervix: It should be soft and elastic, and closely applied to the presenting part.
❖
Measure the dilatation of the cervical os by inserting middle and index fingers into the open cervix and gently opening the fingers to reach the cervical rim (distance in centimetres between the outer
aspects of both examining fingers).
0 cm indicates a closed external cervical os (See Figure 2.8).
-0- 10 cm indicates full dilatation.
13. Check cervical effacement: Progressive shortening and thinning of the cervix during labour is
assessed in percent (%). Thick and elongated cervix is an uneffaced cervix (See Figure 2.8)
while a thinned out/ membranous cervix is fully effaced cervix.
❖
If the cervix is well applied to the presenting part, it is a favourable sign.
❖ If the cervix is not well applied to the presenting part, is a flag to be alert.
14. Check status of membranes: Intact membranes can be felt as a bulging balloon during a
contraction through the dilating os. If membranes are ruptured check the colour of liquor/
amniotic fluid
❖
Refer urgently if amniotic fluid is meconium-stained and delivery is not impending.
❖
Be prepared for resuscitation of newborn, if labour is impending and refer once stabilized.
15. Check presenting part:
❖ Judge if it is hard, round and smooth and the suture lines are felt. If so, it is the head.
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Intact membranes
Refer urgently
❖ If the umbilical cord is felt (cord presentation)
If breech presentation (buttocks or legs at the cervix)
If transverse lie (arm or shoulder felt at the cervix)
♦♦♦ If face presentation (might feel mouth/no sutures palpated)
Figure 2.8: Cervical dilatation, effacement and status of membranes
16. Check station of the presenting part: Station of presenting part is its position relative to the ischial
spine, pelvic inlet and pelvic outlet. It is recorded as "x" centimeters above or below the ischial spine
which is level 0.
<♦ When the fetal head is at the same level as the |
ischial spines, this is called station 0.
I ST
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Figure 2.9: Station ofpresenting part
❖ If the head is higher up the birth canal than the
ischial spines, the station is given a negative
number. At station -4 or -3 the fetal head is still
'floating'
❖ If the fetal head is lower down the birth canal
than the ischial spines, the station is given a
positive number. At station +1 and even more
at station +2, the presenting part of baby's head
bulging forward during labour contractions
could be seen
<♦ At station +3 the baby's head is crowning, i.e.
visible at the vaginal opening even between
contractions. The cervix should be fully dilated
at this point.
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17. Check for pelvic adequacy:
Try to reach the sacral promontory (The most
prominent anterior projection of the base of the
sacrum) if the head is not engaged. If the sacral
promontory is felt, the pelvis is contracted.
❖
If the sacral promontory is not felt, trace
downwards and feel for the sacral hollow. A
well-curved sacrum is favourable.
Figure 2.10: Checking pelvic adequacy
Refer the woman to the higher facility
❖
For instrumental or cesarean section as necessary if both ischial spines
are felt at the same time with fingers when spread. This means the pelvic
cavity is contracted (CRD).
18. Complete the procedure
.
❖
Remove fingers from the vagina gently. Examine the glove for meconium, blood.
❖
Remove the gloves by turning them inside out. Dispose in a leak-proof container or plastic bag.
❖ Soak gloves if they have to be re-used, in 0.5% chlorine solution for 10 minutes to decontaminate
them. Then wash them and dry thoroughly, sterilise (maximum only 3 times).
❖ Wash hands thoroughly with soap and water, dry with a clean, dry cloth or air dry.
<♦
Inform the woman about the findings and reassure her.
❖
Record all findings from the vaginal examination on the partograph (See details in Chapter 3, page no:
36-38) given in the case sheet (see Volume 1 Annexure). Use the partograph only if the woman is in
active labour (cervix dilated 4 cm or more and at least two uterine contractions per 10 minutes, each of
20 seconds duration). If she is not in active labour, note down findings in the case sheet.
Remember
The partograph is a graphical presentation of the progress of labour, and of fetal
and maternal condition during labour. It is a tool to help detect whether labour
is progressing normally or not, and to warn the staff nurse if there are signs of
fetal distress or if the woman's vital signs deviate from the normal range.
Mentors' Manual Volume 2
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Chapter 2
2.5 Mentoring Skills
The following methods could be used to mentor the staff on initial assessment of a woman in labour:
Sample example of one to one mentoring - previous investigations
❖ Use the information during one to one mentoring at the PHC.
❖ Check with the staff nurse at the PHC during a mentoring visit if a woman had any investigations done
in this pregnancy and also check if the details have been documented in the case sheet.
❖ Help the staff nurse with how to interpret the tests as provided in the table below.
Inference
Test
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❖ Less than 7gm/dl indicates severe anemia needs referral.
Hemoglobin gm/dl
❖ Less than 11 gm/dl indicates anemia.
❖ Rh-ve needs referral
<♦ If woman's group is O and the baby's group is A or B there is
a chance of red blood cell breaking down faster than usual
Blood group and Rh
(hemolysis). This can cause jaundice in the baby
Test for Syphilis (RPR/VDRL) '*
TestforHIV
Reactive or Positive (needs referral)
Hepatitis B (HbsAg)
Malaria
Urine test for protein
❖ If +/++/+++/++++ is an indicator of pre-eclampsia and its severity
Urine test to check for infection
<♦ If positive, needs stabilization and treatment
Oral
glucose
(OGTT).
tolerance
test
❖ If any one reading is more than the reference values, it indicates
Gestational Diabetes. (Not done routinely for all women, but
based on history or presenting symptoms)
<♦ Single/ multiple gestations, gestational age, location of placenta,
Ultrasound
presentation, adequacy of liquor, congenital anomalies may also
be documented in the USG report.
Any others
KI
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❖ Check with staff if all tests done have been documented in the case sheet along with date
and results.
❖ Reinforce the importance of interpreting the results
❖ Also determine if the tests have to be repeated and record the test results in the case sheet. Reaffirm
the staff's motivation and ability to interpret results.
Sample example of abdominal examination demonstration by mentor
❖ This could be planned or based on need during a mentoring visit.
❖ If possible check if there is a woman on whom the nurse can demonstrate abdominal examination to
elicit the fetal lie, presentation, FHR.
❖ Introduce self to the woman and seek permission for performing the procedure.
❖ Encourage the staff to demonstrate the procedure.
❖ Affirm the correct steps.
❖ Then ask her if there were some steps that she thought could be done better.
❖ Use pictures for abdominal examination and check if the nurse was able to identify or demonstrate
on model or pillow, correct or wrong steps.
❖ Demonstrate steps if needed. Refer to the case sheet during the process.
❖ Ask the staff nurse to demonstrate the steps back. Affirm the correct steps.
Sample example of case scenario for history taking that can be used for a group
mentoring session
Case Study 2.1: - Part i: Norma!Pregnancy- History andInvestigations
A 24 year G2 PI presents to the PHC with contractions. What specific information would you like to ask her
about on history?
Case Study 2.1: - Part ii: Physicalexamination
The woman is 39 weeks gestation. Her last delivery was 2 years ago. She had a normal vaginal delivery of a
live born male infant, weighing 2700gm at term. She had no complications in her pregnancy or labour. For
the present pregnancy, she has been having regular antenatal care. She is otherwise healthy, has never had
surgery, is not taking any medications and does not have any allergies. Her contractions began 3 hours ago.
They are every 5 minutes and are becoming closer together and stronger. She has not felt her water break
and she can feel good fetal movement.
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What would you like to do on physical examination?
What do you think you should focus on when performing a physical examination on this woman?
Sample case scenario for calculation of LMP
i.
Case study 2.2: LMPknown
Laxmi, who is 18 years old, says she got her last period on January 21 st, 2011. She wants to know when
she will deliver. Calculate her due date.
ii. Case study 2.3: LMP not known
Seema, who is 30 years old, comes to you and says that she has not got her period for the past three
months. She last got her period on the day before Holi, i.e. March 10. Calculate her due date.
iii. Case Study 2.4 (optional): Irregular cycles
Mrs. Rekha, 24 years old primigravida comes to OPD with 6 months amenorrhea. This is her first visit to
you. How will you calculate the EDD with regular and irregular cycles?
Key (Answer for Case Study 2-4):
Case Study 2.2 Answer: 9 calendar months + 7 days, i.e. September 28th, 2011
Case Study 2.3 Answer: 9 calendar months + 7 days, i.e. December 16
Case Study 2.4 Answer:
❖ H/O regular periods: Add 9 months and 7 days to the LMP
❖ Cycles more than 28 - 30 days: Add the extra number of days to arrive
at EDD
Cycles less than 28 days: Subtract the number of days from the EDD.
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2.6
.
Key Messages-Do's and Don'ts
DO follow up presenting complaints. The presenting complaints if altered serve as
red flags for the nurse to do something else in order to arrive at a diagnosis.
DO calculate gestational age. Knowing how to calculate gestational age is
important because it provides an estimated due date. It thus will help to know if
the baby would be preterm or not or if the baby's growth would be appropriate.
DO take vital signs and see if they are abnormal. Abnormal vital signs indicate
complications that require management before referral.
DO a proper abdominal examination. The symphsis fundal height plus or minus
3 cm (which could be more or less than the gestational age) usually is equal to
the gestational age in weeks. A measurement that is more than 3cm different
indicates a problem that needs PHC staff to be alert.
Do's
DO listen to the fetal heart. A fetal heart rate that is absent or that is less than 120
or greater than 160beats/minute is not normal and needs referral.
DO assess for prematurity. Prematurity (gestational age less than 37 weeks) always
needs to be ruled out when a woman presents to the PHC.This is especially
important if the woman is in labour or has rupture of membranes.
DO always check to see ifplacental location is known. This is important to rule out
placenta previa.
DO always make sure the woman is stable before referral. When a complication is
diagnosed there is always something that could be done at the PHC to make the
woman stable. The case sheet will guide you. Refer only after taking initial steps of
management.
DO always use case sheet as a job aid for every case and ensure complete
documentation.
DO NOT hesitate to call the medical officer or district program specialist when in
doubt or if there is a complication detected.
Don'ts
DO NOT perform a pelvic examination if there is bleeding per vagina and the
placental location is not known, or the woman is known to have placenta previa
or low lying placenta, as it could lead to severe bleeding. (If the location of
placenta is known and placenta previa is ruled out pelvic exam can be done).
DO NOT perform a pelvic examination if the membranes have ruptured and the
woman is not in labour. This can lead to infection.
DO NOT refer a woman without starting initial management (stabilizing) her first.
There is always something that could be done prior to referral.
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Labour and Delivery
Reference: SBA guidelines 2010 Page 43-52
Learning Objectives:
At the end of this chapter you will be able to
❖ Recall the stages of labour, components of and how to do labour monitoring, the significance
of using the partograph
❖ Demonstrate how to monitor progress of labour using the partograph in a woman admitted
to the PHC, and how to manage all four stages of labour
❖ Demonstrate the correct documentation of the partograph and case sheet for all stages of
labour, for a woman admitted to the PHC
❖ Demonstrate mentoring skills for use of partograph in first stage of labour, management of
second to fourth stages of labour, including monitoring and progress of labour in a woman
•
admitted to the PHC
3.1 Introduction
Normal labour is the spontaneous process of expulsion of the fetus and placenta. It is made up of four
stages. Keen observation, monitoring using the partograph (a graphic tool) and support during this
crucial period would help in managing it correctly or in identifying complications and thus enable starting
initial management before referral. This could ensure a successful outcome for woman and newborn. The
intrapartum and immediate postnatal period is a critical time; worldwide nearly half of all maternal deaths
and one-third of all stillbirths and neonatal death occur during this period. Both the third and fourth stages
of labour are critical time periods where early postnatal hemorrhage can occur. In northern Karnataka as
in rest of India, postnatal hemorrhage remains the leading cause of maternal death. Since complications
can occur during all stages of labour, each stage of labour has to be monitored closely in order to detect
complications and take prompt action.
3.2 Components of Labour and Delivery
Determine if the woman is in true versus false labour
It is not uncommon for women to experience some contractions as their pregnancy progresses, but this
does not mean they are in labour. This could occur more often for a primigravida. A nurse must be able to
differentiate between true and false labour.
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Identify the stage of labour and monitor it progress
There are four stages of labour, all of which are important and need to be monitored carefully by a skilled
birth attendant.
❖ The first stage of labour is from the onset of true labour pains to full dilatation of the cervix.
❖ The second stage is from full dilatation of cervix till delivery of the fetus.
❖ The third stage is from expulsion of fetus to delivery of the placenta.
❖ The fourth stage is from delivery of placenta till 2 hours of delivery. Close monitoring during these
stages could help to identify complications early, start initial management and referring the woman
early for appropriate management
Conduct the delivery, including active management of the third stage oflabour (AMTSL)
A skilled birth attendant could conduct the delivery of a woman. Readiness for the second stage, adequate
preparation could help the nurse to conduct the delivery effectively. The nurse must practice AMTSL to
reduce the risk of bleeding.
Initiate immediate postnatal care
This is an important period since most maternal deaths could occur during this period. It is important to watch
the woman carefully during this period and be aware of the risk for post partum hemorrhage or bleeding.
3.3 Importance of Components of Labour and Delivery
Determine whether woman is in true or false labour
True labour consists of regular uterine contractions that increase in frequency and intensity and leads to
increase in cervical dilation and effacement. Knowing when true labour has actually started is important
as this acts as the point from which we monitor progress and decide whether any intervention is needed.
Misdiagnosing someone when they are not in labour can lead to unnecessary procedures and interventions
being performed.
Identify the stages of labour and monitor its progress
Knowing the stage of labour is important to identify whether labour is progressing normally or there are
some urgent complications that have to be referred after initial management. The first stage is the period
from the onset of labour pain to the full dilatation of the cervix i.e. to 10 cm. The first stage takes about
8 hours in a primigravida and 6 hours in multigravida. If it takes longer than this to reach full dilation or for
the fetus to descend, this is a red flag that something is wrong, such as prolonged or obstructed labour (see
complication case sheet A).
Labour has two phases, a latent phase and an active phase.
In the latent phase, the contractions will not be regular, both cervix dilatation (less than 4 cm) and
thinning of the cervix (effacement) is slow. It can vary in duration from hours to days. On the case sheet
a separate area is provided to monitor a woman in latent labour that is separate from the partograph
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(see details following). Complications can occur in the latent phase, it is thus important to monitor the
vital signs (BP, pulse, temperature and respiration) and fetal heart rate in this phase. Any abnormalities
could be a flag for a developing complication. It is important to also monitor the cervical dilatation every
4 hours to determine when the woman is in the active phase (cervical dilatation of 4cm)
❖ In the active phase the cervix dilates faster and the fetus descends. The active phase begins when the
cervix is 4 cm dilated and the contractions are strong and regular.
Monitoring the progress of active labour by plotting on a partograph
Using a partograph could help to follow the progress of labour, as well as the condition of the woman and
the fetus. It is a graphic recording of the pelvic examination findings (cervical dilation, effacement, station,
status of membranes), the fetal heart rate, the frequency and strength of contractions and the vital signs
of the woman. It is a tool that helps assess the need for action and recognizes the need for referral at the
appropriate time, thus facilitating timely referral and pre-referral management.
The information in the partograph is to be recorded at various time intervals in four separate graphs:
❖
Graph A and B record labour progress:
<
Once a woman has entered active labour (dilatation of 4 cms or more), the rate of cervical
dilation should be at least 1 cm per hour, although it may be faster (1.2-1.5 cm per hour).
Cervical dilation that is less than 1 cm per hour in the active phase is called prolonged labour
or has stopped altogether on Graph A is called obstructed labour and requires referral (see
complication case sheet A).
-0-
Uterine contractions that are not frequent and intense on Graph B also indicate prolonged or
obstructed labour and require referral (see complication case sheet A).
❖
Graph C records the maternal condition: Maternal vital signs, if abnormal serve as a red flag to check
what the underlying cause is. It is then important to start initial management and get help of a doctor
immediately.
❖
Graph D records fetal condition. If the fetal heart rate is greater than 160 or less than 120 beats per minute
on Graph D, this is a flag that there is fetal distress and referral to a higher centre should be made (see
complication case sheet H).
It is important to know how to plot and read the partograph to recognize and diagnose any abnormalities
or complications of labour progress, maternal and fetal well being.The partograph must be used only
when the woman is in active labour (dilatation of 4 cms or more). If it is used before the active phase it
could lead to the wrong impression that the labour is abnormal, and thus to unnecessary interventions
and procedures. Once the woman has entered the active phase of labour, information collected must be
recorded on the case sheet in the labour monitoring section, andon the partograph.
❖ The PV examination must be plotted once every 4 hours. Cervical examination is not done more often
H
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than this to reduce the risk of intra-uterine infection in the woman.
<♦
Blood pressure and temperature are also checked every 4 hours. Abnormalities can indicate complications:
<
High blood pressure may indicate hypertensive disease;
Low blood pressure can indicate bleeding, infection or shock;
Raised temperature can indicate infection.
❖
Fetal heart rate and maternal pulse is done more frequently (every half hour) since abnormalities in
these parameters are often the first clues to a developing complication:
Rapid and low volume pulse can indicate bleeding, shock;
<
Rapid EHR (more than 160/minute) or low FHR (less thanl 00/minute) could indicate fetal distress.
How to plot and interpret the partograph is covered in the clinical skills section and could be used as a
reference during mentoring.
Supportive care during labour
This may involve emotional support, comfort measures, information and advocacy. It helps create a
positive birthing experience,for the woman and her family. These measures may increase physiologic
labour processes as well as woman's feelings of control and competence, and thus could reduce the
need for obstetric intervention. The ways in which supportive care can be provided include
❖
Encourage, praise, and reassure the woman by speaking in a calm and soothing voice: This could be
comforting and relaxing for her
❖ Maintain respect and privacy at all time: This can be done by explaining all procedures, asking
permission and sharing findings: It also makes sure that the basic client rights are met
Sharing information and seeking permission could help the woman to have a sense of control over the
labour experience. Privacy could ensure that she feels comfortable and secure during this vulnerable
time.
❖
Make sure that the delivery room is warm (ideal temperature is 25OC-28°C; best way to know is if you
are comfortable) and clean: A warm room could help keep the woman comfortable. It could also help
make sure that the baby stays warm when delivered.
❖ Encourage walking: The woman must be encouraged and helped if needed to walk around during the
first stage of labour until rupture of membranes. This could help to make the labour shorter and less
painful; with descent of the fetal head and also help prevent the development of fistula if obstructed
or prolonged labour occurs.
❖
Encourage to practice relaxation techniques, such as deep breathing exercises.Deep breathing could
help with pain control and coping with pain during labour
❖ Wipe the forehead of the woman with a damp cloth if needed. Labour is hard work. A damp cloth could
be soothening and comforting.
❖ Remind the woman to empty her bladder every two or so. This could help in the progress of labour.
<♦
Make sure support person is available (like an ASHA or family member) and knows what is expected.
The presence of a support person has been shown to decrease need for obstetric intervention.
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Conduct delivery and do active management of third stage of labour (AMTSL)
The second stage takes about 2 hours for a primigravida and about half an hour to one hour for a
multigravida. If it takes longer than this for the woman to deliver the baby this is a red flag that something
is wrong, such as prolonged or obstructed labour (see complication case sheet A).
When the woman reaches the second stage, she should be transferred to the labour room if she is in
another room.
❖
As the head descends the woman will begin to feel more pressure and start to have the urge to bear
down or push. This sensation can often be confused with feeling as if one has to go the bathroom to
have a bowel movement.
❖ When the woman begins to push it is important to provide perineal support. This helps prevent the
development of third and fourth degree tears.
❖
It is also important to wear sterile gloves and an apron in order to minimize infection risks for both the
woman, newborn and health care provider.
❖
Immediate management of the baby is crucial to prevent complication (Refer to Volume 3 - Chapter 3
for details of immediate management).
The third stage of labour takes about 15 - 30 minutes irrespective of whether the woman is a primigravida
or a multigravida. If after 30 minutes the placenta is still not delivered this is a flag that she has retained
" placenta (see complication case sheet F).
Active management of the third stage of labour (AMTSL) is a procedure that could prevent postnatal
hemorrhage (PPH) and should be done for all deliveries. Before AMTSL it is important to make sure that
there is no twin or another live fetus in the uterus. Active management of the third stage of labour involves
three key steps:
❖
Give a uterotonic drug (Injection Oxytocin) after delivery of baby which increases contraction of the
uterine muscles. This would help in expulsion of the placenta, reduce bleeding and prevent PPH.
❖
Do controlled cord traction (CCT) to assist in the delivery of the placenta, and help reduce the chance
of a retained placenta and thus bleeding, i.e. PPH. It must be applied correctly to avoid complications.
❖
Provide uterine massage to make the muscles of the uterus contract (feels like a cricket ball). The
contracting muscles constrict around the blood vessels and helps decrease bleeding.
PPH could be caused by uterine atony (soft and tender uterus), genital tears or retained pieces of placenta or
membrane, it is important to examine both the placenta once it has been delivered and the woman's perineum.
❖
Estimate the blood loss soon after delivery of the placenta, to recognize if the amount of blood lost is normal.
❖ Check if the uterus is well contracted (feels like a cricket ball) when felt over the abdomen.
❖ Check if placenta is complete or not - missing pieces or lobes is indicative of retained placental products
and requires referral and further management.
*:*
Vaginal/perineal tears can bleed significantly and need to be identified so that they could be
properly repaired.
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Skilled birth attendance care during labour, delivery and postnatal periods at 24/7 Primary Health Centres
First and second degrees tears could be repaired at the PHC.
<
Third and fourth degree tears need initial management and referral for repair to a higher facility.
Initiate immediate postnatal care fourth stage
The fourth stage is an important period as severe postnatal hemorrhage (PPH) can occur during this stage,
which could lead to death of the woman if not managed well. During this period the woman must remain
in the labour room.
Most maternal and newborn deaths occur during the first few hours after delivery. Paying close attention
to vital signs (pulse, BP), uterine tone and vaginal bleeding is important as any abnormalities in them act
as a flag to alert you to ongoing hemorrhage (see complication case sheet F).The following must be done
during this stage:
❖
Encourage the woman to empty the bladder. A full bladder can prevent the uterus from contracting
and lead to postnatal hemorrhage.
❖ Check vital signs (BP/Pulse), vaginal bleeding and uterine tone/height regularly (every 15 minutes) for
the first 2 hours following delivery.
Abnormal vital signs (increasing heart rate, decreasing blood pressure, altered level of alertness)
could make one suspect postnatal hemorrhage. Increase in vaginal bleeding or the amount of
blood on the pad also is a flag for PPH.
Soft and spongy uterus: After delivery a normal uterus will feel hard and firm and be at the level
of or just below the umbilicus. Examining the uterus tells us if the uterus is remaining contracted
or not. A uterus that is soft and spongy/boggy, or that is increasing in size (height above the
level of the umbilicus) is a red flag for postnatal hemorrhage due to uterine atony.
An elevated blood pressure (greater than 140/90 mmHg) and/or seizures during this time indicates
hypertensive disease and eclampsia. This means that initial management must be started to
stabilise the woman, and then she must be referred for further management and treatment.
An elevated temperature greater than 38°C indicates infection. This must be referred for further
management.
❖
Make sure the woman and baby are together and not separated.
❖ Assist woman to breastfeed within 30 minutes as this stimulates the release of oxytocin, which helps
keep the uterus firm, and contracted and thus prevent postnatal hemorrhage.
♦♦♦
Ensure the woman eats well and drinks enough fluids to replace the energy expended during delivery
and to ensure adequate intake to stay healthy postnatal.
♦♦♦
Dispose the placenta in the basin or based on cultural beliefs (give it to the relatives if they request to
complete any religious or cultural rituals).
Clean the room, segregate waste to prevent spread of infection.
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Chapter 3
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3.4 Requirements for Management of Labour and Delivery
Equipments and supplies
Ensure that the following equipment is available at the PHC and in working condition:
❖ Examination table and stepping stool
❖ Blood pressure apparatus
❖ Stethoscope
❖ Thermometer
❖ Fetoscope
❖ Case sheet
❖ HID gloves, goggles, apron, mask
❖ One sterile tray to conduct delivery
2 artery forceps
<
1 thumb forceps
Sterile gloves
> Scissors to cut cord
Cord tie/clamp
Sterile cotton swabs
Sterile pad
Sterile gauze pieces
Kidney tray
Towels to wrap the baby
❖ Disposable needles and syringes
Episiotomy scissors if needed
❖ Local anesthetic (Inj Lignocaine 0.5% 10ml) with syringe and needle
❖ Suturing set (artery forceps, scissors, forceps/pickups); absorbable sutures - chromic, polysorb if
needed
❖ Disinfectant solution- 0.5% bleach solution
❖ Antiseptic solution - savlon or betadine
❖ Kidney tray
❖ Basin to collect placenta
❖ One puncture proof container to discard needles and other sharps
One leak poof container to dispose soiled linen
♦♦♦ Watch / clock to note time for different stages of labour
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❖ Measuring tape
❖ Adhesive tape to put identity hand on the baby
❖
Emergency medication
Inj Oxytocin (1OIU preferred)
Tab Misoprostol 600mcg (available as 200mcg strength)
<
Inj Magnesium sulfate
<
Inj Ergotamine 0.2mg
Cap Nifedipine 5mg
<
Inj Hydralizine 5mg
IV drip Normal saline
<
IV drip Ringer lactate
IV set with Venflon/butterfly
Adhesive tape or micropore
Inj Ljgnocaine 10 mL 0.5% solution
❖
Pads for woman
❖ Madilu kit for those eligible
Newborn corner
Clinical skills
How to assess vital signs and perform a pelvic examination has been outlined in Chapter 2 and has not
been repeated here. Please refer to it for details.
Management of FIRST STAGE OF LABOUR AND PLOTTING THE PARTOGRAPH
1
Fill out the labour monitoring section of the case sheet when a woman comes to the PHC with
labour pains.
❖ This consists of an identification section, monitoring section and the partograph.
❖ First, fill in the identification data in the case sheet - name, age, parity, date and time of admission,
registration number, date and time of rupture of membranes.
❖
Fill in the latent phase component of the labour monitoring sections if the woman is in latent phase.
Do not plot information from the latent phase on the partograph. If she is already in active labour
then you can go straight to the active phase component of the monitoring section and also begin
plotting on the partograph.
Plotting the PARTOGRAPH
1
Determine the next steps of management. Refer urgently, after initial management and stabilization,
any complications such as:
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Chapter 3
❖ Rupture of membranes more than 12 hours,
❖ Prolonged or obstructed labour,
❖ Pre eclampsia, eclampsia,
❖ Antepartum hemorrhage
❖ Infection
❖ Fetal distress
❖ No fetal movements
❖ Review the current reading, at every step of plotting the partograph, in relation to the previous
reading and determine if there is a deviation from the normal.
GRAPH A: Labour
1
Start plotting the dilatation at 4 centimetres or more with an X on Line A corresponding to the
cervical dilatation at first evaluation. NOTE -The first reading will always be on Line A. Record the time
corresponding to this reading. The reading on all other parameters should be plotted keeping this as
the starting point. Each box represents half an hour or 30 minutes.
2
Measure and plot with an X every four hours.
I
Cervical Dilatation
Hours 10
Time 00
14
00
io
9
8
7
6
5
4
Always plot the first reading of cervical dilatation on Line A.
Then plot the time corresponding to this reading
Figure 3.1: Plotting cervical dilatation on partograph
GRAPH B: Labour
1
Count contractions for 10 minutes every half an hour and record with an X.
2
Record the duration of contractions each time in seconds, in the box denoted.
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Skilled birth attendance care during labour, delivery and postnatal periods at 24/7 Primary Health Centres
Plotting of Contractions
Time
Contractions
5
No. per ten
4 -----
minutes
3 -----
>e
2)^
1
Duration of
20 20 30 30 30
Sec Sec Sec Sec Sec
Contraction
in seconds
Figure 3.2: Plotting contraction on partograph
GRAPH C: Maternal condition
1
2
Record the pulse of the woman with an X at every half hour.
Record the blood pressure every four hours using the sign with the top arrow denoting systolic BP and
the lower X denoting diastolic BP.
3
Record the temperature in Celsius in the box denoted every four hours.
Plotting of Pulse, BP, Temperature
180
160
140
Pulse
and
120
A
BP
V
100
>
X X
80
V X
>
>
X
>
60 —L—
Temperature
38
37.4
Figure 3.3: Plotting vital parameters on partograph
Mentors' Manual Volume 2
Chapter 3
GRAPH D: Fetal condition
1
Record the FHR with an X every half hour.
2
Record the status of membranes and amniotic fluid with I, C, B, M where I means intact membranes;
C means clear amniotic fluid; B means blood stained amniotic fluid; M means meconium stained.
Plotting Foetal Heart Rate
180
160
>
140
Foetal
Heart
120
Rate
100
5
/
,_ Z
E
80
Status of
membranes
60
I
I I
I C C C
Figure 3.4: Plotting contraction on partograph
Preparation of LABOUR ROOM
1
Ensure that the oxygen cylinder with flow meter, suction apparatus, and UPS are in working condition
at each shift.
2
Keep the equipment, supplies and drugs necessary for conducting a delivery ready.
3 Allow the woman to adopt the position of her choice: semi-sitting or lying on her back with her legs
raised/flexed.
4
Maintain privacy (place a curtain or screen).
5
Tell the woman and her support person what is going to be done.
6
Encourage the woman or support person to ask questions.
7
Listen to what the woman and her support person have to say.
8
Provide emotional support and reassurance.
Conduct a VAGINAL DELIVERY
I.
Identify signs of delivery
❖ Transfer the woman to the labour room when she reaches this stage, if she is in another room.
Advise her not to walk during this stage, especially when the membranes are ruptured to avoid cord
prolapse.
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2
Continue to monitor the frequency and duration of the contractions, every half an hour.
❖ Count the number of contractions occurring every 10 minutes and the duration in seconds,
❖
Monitor the FHR every five minutes. Being alert for any emergency sign is important.
3. Conduct the delivery
❖
Remove all jewellery, and put on a clean plastic apron, and shoes/shoe cover.
❖
Place one clean plastic sheet from the delivery kit under the woman's buttocks.
❖ Wash hands thoroughly with soap and water, and dry them with a clean, dry cloth or air dry.
❖
Do check to see if woman is eligible to be a beneficiary of the Madilu kit programme of the Govt
of Karnataka (based on social and economic status); if so, ensure documents are obtained and the
Madilu kit is opened at the time of delivery.
The madilu kit contains two towels that could be used to wipe the baby dry and wrap the baby
❖ Wear sterile gloves on both hands and clean the perineal area from above downward towards the
anus and from labia minora outward towards the thighs with cotton swabs dipped in antiseptic lotion.
i. Head floating, before engagement
2, Fatgagement.. flexion, descent
1. Further descent, int ernal roution
4. Complete rotation, beginning
extension
5. Complete extension
6. External rataUoD of bead and
infernal rotation of shoulders
7. Delivery of anterior shoulder
«. Delivery of posterior shoulder
Figure 3.5: Process of delivery
4. Delivery of the head
❖
Keep one hand gently on the head, as it advances with the
contractions, to maintain flexion.
❖
Support the perineum with the other hand, using a clean pad.
Give good perineaLsupport to prevent perineal tears. Leave the
perineum visible (between the thumb and the index finger).
The best time to give perineal support is when the woman has a
contraction; the perineal skin is stretched
39
Figure 3.5: Process of delivery
Mentors' Manual Volume 2
Figure 3.6: How to give perineal
J
support
Chapter 3
❖ Ask the woman to take deep breaths and bear down (push) only during a contraction.
<♦ Wipe the baby's face once the head is out. Clean the mucus with a clean piece of gauze.
❖
Feel around the neck gently for the cord.
If the cord is around the neck but is loose, slide/slip it over the baby's head.
<
If the cord is tight around the neck, clamp the cord with two artery forceps placed 3 cm apart,
and cut the cord between the two clamps and unwind it.
5. Delivery of the shoulders and the rest of the baby
❖ Wait for spontaneous rotation and delivery of the shoulders. This happens in about 1-2 minutes.
❖ Apply gentle pressure downwards to deliver the anterior shoulder.
❖
Deliver the posterior shoulder by lifting the baby up, towards the woman's abdomen.
❖ Observe as the rest of the baby's body follows smoothly.
❖ Place the baby on the woman's abdomen over a warm clean cloth or towel.
❖ Check if the baby has cried or is breathing.
❖ Wipe the baby, clamp and cut the cord and place baby for skin-to-skin contact between woman's ’
breasts. Cover the baby with another clean warm towel. (See details under Volume 3, Chapter 3Routine care of newborn in the first hour after birth).
6. Document: Date, time, sex of the baby and other details as outlined in the case sheet.
Third stage of Labour: ACTIVE MANAGEMENT OF THIRD STAGE OF LABOUR (AMTSL)
Before administering AMTSL, rule out the presence of another baby by palpating the abdomen and trying
to feel for fetal parts. AMTSL has three parts namely administration of oxytocin, controlled cord traction
and uterine massage that are described below.
1. Give IM Injection oxytocin
❖ Wash hands.
<♦ Withdraw 1 ml if 10 lU/ml of Oxytocin is available. If 5 lU/ml, break two ampoules and withdraw
2 ml in a disposable syringe with 22/23G needle. Ensure that there are no air bubbles in the syringe.
❖
Explain to the woman that an injection will be given to help decrease the bleeding.
❖
Uncover the area to be injected (lateral upper quadrant of buttocks- major gluteal muscle, lateral
side of upper leg or upper part of arm).
❖ Disinfect the skin with an alcohol swab.
❖ Tell the lady to relax the muscle.
❖
Insert the needle swiftly at an angle of 90 degrees (watch depth!).
❖ Aspirate briefly; if blood appears, withdraw needle. Replace it with a new one, if possible, and inject
again at another site.
❖
Inject slowly (less painful).
40 ’
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Skilled birth attendance care during labour, delivery and postnatal periods at 24/7 Primary Health Centres
❖ Withdraw needle swiftly.
❖
Press sterile cotton wool onto the injection site.
❖ Check the woman's reaction and give additional reassurance, if necessary.
❖
Dispose waste safely; wash your hands.
2. Perform controlled cord traction (CCT)
❖ Assure the woman that delivering the placenta will not hurt, because it is much smaller and softer
than the baby.
❖
Hold the clamped end of the umbilical cord with one hand and place the other hand just above the
symphysis pubis, for counter traction (see Figure 3.7).
❖
Maintain tension on the cord and wait for a contraction.
❖
Pull gently the cord downwards to deliver the placenta, only during a contraction.
❖
Push upwards with the other hand, by applying counter- traction. (If the placenta does not descend
within 30-40 seconds of CCT, do not
continue to pull on the cord. Wait for about
X
\
5 minutes for the uterus to contract strongly,
then repeat CCT with counter-traction).
❖
Hold the placenta with both hands to
prevent tearing of the membranes, when it
V
metal c top
delivers.
❖ Gently twist the membranes so that they are
expelled intact.
❖
Place the placenta in a tray or plastic bag,
as feasible.
pbucnta
Figure 3.7: How to perform CCT
3. Perform uterine massage
❖
Place cupped palm on the uterine fundus and feel for the state of contraction.
❖ Massage the uterine fundus in a circular motion with the cupped palm until the uterus is well
contracted. A well-contracted uterus feels hard like a cricket ball.
❖ Place the fingers behind the fundus, when the uterus is well contracted, and push down in one swift
action to expel clots.Tell the lady to relax the muscle.
4. Examine the PLACENTA, MEMBRANES, PERINEUM AND UMBILICAL CORD
❖
Examine maternal surface of placenta
Hold the placenta in the palms of hands, keeping the palms flat (see Figure 3.8). Make sure that
the maternal surface is facing you.
-0-
Check if all the lobules are present and fit together.
Suspect that some placental fragments are retained in the uterus if any of the lobes are missing
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Chapter 3
or the lobules do not fit together.
<♦ Examine fetal surface of placenta
Hold the umbilical cord in one hand and let the placenta and membranes hang down like an
inverted umbrella (see Figure 3.9).
Look for holes, which may indicate that a part of
the membrane has been left behind in the uterus.
Lookfor the point of insertion of the cord (the point
where the cord is inserted into the membranes
and from where it travels to the placenta).
❖ Examine membranes
> Place the membranes together and make sure
that they are complete.
❖ Examine umbilical cord
Wipe the tip of the umbilical cord with a sterile
cotton swab
Figure 3.8: How to examine maternal surface
ofplacenta
Inspect the umbilical cord if it has two arteries and
o one vein. Suspect for congenital malformation if
only one artery is found.
Infection control measures- HOW TO DISPOSE THE PLACENTA
1. Keep the gloves on.
2. Put the placenta into leak-proof yellow biodegradable bag
containing bleach or hand over to relatives if requested
for religious purposes. If handed over to relatives inform
them how to dispose it safely and to wear gloves when
handling the placenta.
3. Dispose the placenta in a safe and culturally appropriate
manner for incineration or burial (at least 10 metres away
Figure 3.9: How to examine fetal surface of
placenta
from a source of water in a pit that is 2 metres deep).
4. Remove gloves inside out.
5. Place them in a leak-proof container or plastic bag if the plan is to discard them.
6. Submerge in 0.5% chlorine solution if the surgical gloves are to be re-used for 10 minutes and then
wash, drip dry it. Once dry apply powder and store in appropriate place. Steam sterilize if it is to be
reused for next delivery. Do not reuse if adequate number of single use gloves are available.
7. Wash hands thoroughly with soap and water, dry them.
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Immediate post-delivery CARE OF THE WOMAN
1. Keep the woman warm and comfortable.
2. Monitor the following every 15 minutes for first 2 hours:
❖ General condition;
❖
BP and pulse;
❖ Vaginal bleeding and estimation of blood loss;
❖
Uterus, to make sure it is well contracted by assessing tone and height.
3. Check temperature every hour.
4. Examine the vagina and perineum immediately after delivery to check for tears.
5. Estimate the blood lost
❖ Collect the blood in a container or over a clean plastic sheet placed close to the vulva.
❖
Estimate and record the amount of blood lost as average or heavy.
To determine if the bleeding is average or heavy estimate the amount of blood loss
using one of the following methods:
❖ Count the number of pads soaked (soaking a pad in less than 5 minutes
is heavy)
❖ Observe for any continued gushing of blood from the vagina or passage
of a number of large clots (heavy bleeding).
Examine for LOWER VAGINA AND PERINEUM
FOR TEARS
1. Inspect the lower vagina and perineum when
estimating blood loss.
2. Ensure that adequate light is falling onto the
■ -
x
perineum.
3. Separate gently the labia and inspect the
perineum
and
vagina
for
bleeding
and
lacerations/tears.
4. Carefully examine the vagina, perineum and
cervix under good light to determine the type
of tear. There are four degrees of tears that can
occur during delivery
❖
Most first degree tears (vaginal tissue
only) heal without repair, unless they are
actively bleeding.
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Figure 3.10: How to check for perineum tears
❖ If the tear is long and deep through the perineum, rule out a third or fourth degree tear:
To do so place a gloved finger in the anus.
Gently lift the finger and identify the anal sphincter, feeling for the tone or tightness of the
sphincter.
If the tone of the sphincter is not there, suspect a 3rd degree tear.
< If there is an obvious tear in the anus and rectal mucosa this is a fourth degree tear.
Check the UTERUS FOR TONE AND HEIGHT postnataly
1. Once the delivery of the placenta is completed, place one hand over the abdomen and feel for the
fundus of the uterus.
❖ The consistency of the uterus must be hard (like that of a cricket ball).
❖ The uterus should be at the level of the umbilicus.
2. Check every 15 minutes if the uterus is well contracted, i.e. hard and round.
How to CARE FOR THE PERINEUM
1. Clean the vulva and perineum gently with warm water or an antiseptic solution and dry with a clean,
soft cloth if no lacerations are present.
2. Place a dean/sun-dried cloth or pad on the woman's perineum.
-
-
3. Remove soiled clothes/linen to make the woman comfortable
Immediate POSTNATAL CARE (1 HOUR OF BIRTH) -INITIATION OF BREASTFEEDING, PERSONAL CARE
1. Keep the mother and the newborn together.
2. Ensure that the madilu kit is used and the baby is kept warm by wrapping with the towel in the kit.
3. Encourage and help the mother to start breastfeeding, including colostrum, as early as possible/within half
an hour of birth (See Volume 3, Chapter 5). The oxytocin produced during the act of breastfeeding will help
keep the uterus contracted.
4. Encourage the woman to
❖ Take adequate fluids and rest.
❖ Clean herself well after passing urine.
❖ Pass urine frequently.
❖ Report any difficulty immediately (difficulty to pass urine, difficulty to pass stool, too much bleeding,
foul smelling discharge, pain in the breasts or head or perineal region, feeling hot, unable to feed
the baby).
5. Watch the woman and also ask the support person to call if the woman develops any of the following:
❖ Increase in P/V bleeding;
❖ Severe headache;
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Skilled birth attendance care during labour, delivery and postnatal periods at 24/7 Primary Health Centres
❖ Visual disturbance;
❖
Epigastric pain;
❖ Convulsions;
❖
Inability to pass urine.
6. Counsel the woman and family members in the event of a referral for any complications on the following:
❖ Why she needs to be referred;
❖ Where she would /should be taken;
❖
How she should be transported;
❖ With whom she would be transported;
❖ What she must do during transport if the baby is with her.
Care of the NEWBORN
1. Shift the mother and baby to the ward for further care in the postnatal period if no complications arise,
when both are stable (Refer to Volume 3, Chapter 3-8 for details).
3.5 Mentoring Skills
The following methods could be used to mentor staff nurses on assessing and managing a woman during
labour and delivery in the PHC:
Sample forteaching a staff nurse or staff nurses about identification of true labour.
♦♦♦ This can be a planned group teaching but depending on the situation, it could be also used as a one
to one teaching.
❖ Give participants a scenario,"a 20 year old woman comes to the labour room with a history of abdominal
pains since 4 hours.This is her first pregnancy and she is 36 weeks pregnant. What would you ask, look
for, feel to decide if this is true or false labour pains?"
❖
Help the participants to identify those features that will differentiate between true and false labour
-0-
Additional information that would need to be collected include: if pain is regular, where pain is felt
first, whether associated with contractions and continues irrespective of activity, whether there is
show.
<
If answer is no then it is false labour.
❖ Use the information in Table 3.1 below to list all features of true labour.
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Table 3.1 Difference between true and false labour pain
True labour pain
False labour pain
❖ Begins irregularly but becomes regular and ❖ Begins irregularly and remains irregular
predictable
❖ Usually felt first abdominally and remains
❖ Felt first in the lower back and sweeps around
confined to the abdomen and groin
to the abdomen in a wave pattern
❖ Often disappears with ambulation or sleep
❖ Pain is associated with contraction of the uterus
❖ Increases in duration frequency and
intensity with the passage of time
❖ Continues no matter what the woman's level
of activity
❖ Show absent
❖ Increases in duration frequency and intensity ❖ Does not achieve cervical effacement and
with the passage of time
dilatation
❖ Accompanied by show (blood stained mucus
discharge)
I
❖ Achieves cervical effacement and dilatation
❖ Accompanied by descent of the presenting part
J
Sample exercise for mentoring staff on use ofpartograph
1, Partograph exercise 3.1 -(Total time 15min)
Step 1: Mrs. Chitra, wife of Ramesh, aged 27years, was admitted at 9.00 a.m. on 12.5.2012. Membranes
ruptured 8.00 a.m. She is Gravida 4, para 3+0. Her Hospital number 6639. Initial assessment done at the
PHC gave the following findings:
a) The cervix is 5 cm dilated
b) There are 3 contractions in 10 minutes, each lasting 30 seconds
c) FHS140/min
d) Amniotic fluid clear
e) Blood pressure 120/70 mmHg
f) Temperature 36.8°C
g) Pulse 80 per minute
Step 2: Monitoring of labour gave the following findings:
9.30 a.m. FHS 130/min, Contractions 3/10 each 35 sec, Pulse 80/min, liquor clear
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❖ 10.00 a.m. FHS 136/min, Contractions 3/10 each 40 sec, Pulse 90 /min, liquor clear
❖ 11.00 a.m. FHS 140/min, Contractions 3/10 each 40 sec, Pulse 88/min, liquor clear
❖ 11.30 a.m. FHS 140/min, Contractions 3/10 each 40 sec, Pulse 90/min, liquor clear
❖ 12.00 noon. FHS 130/min, Contractions 3/10 each 40 sec, Pulse 90/min, liquor clear
❖ 12.30 p.m. FHS 130/min, Contractions 3/10 each 40 sec, Pulse 88/min, liquor clear
❖ 1.00 p.m. FHS 140/min, Contractions 3/10 each 40 sec, Pulse 88/min, liquor clear. Blood pressure
100/70 mmHg. Cervix is fully dilated.
Question:
1. What are your diagnoses after plotting the partograph at stepl ? Why did you make these diagnoses?
2 What advice should be given?
3 Compare partograph plotted at step 2?
4. What action will you take?
2. Partograph exercise 3.2
Step 1:
❖
Mrs. Suma was admitted at 5.00 a.m. on 12.5.2010
❖
Membranes ruptured 4.00 a.m.
❖
Gravida 3, para 2
❖
Hospital number 7886
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hHH
❖ On admission the fetal head was 4/5 palpable above the symphysis pubis and the cervix was 2
cm dilated.
Question:
What should be recorded in the partograph?
Step 2:09.00 a.m.
❖ The cervix is 5 cm dilated.
❖ There are 3 contractions in 10 minutes, each lasting 20-40 seconds
❖ Fetal heart rate 120/min
❖ Membranes ruptured, amniotic fluid clear
❖ Pulse 80 per minute
❖ Blood pressure 120/70 mmHg
❖ Temperature 36.8°C
Questions:
What should be recorded in the partograph?
What steps should be taken?
What advice should be given?
What do you expect to find at 1 pm?
Skilled birth attendance care during labour, delivery and postnatal periods at 24/7 Primary Health Centres
Step 3: Plot the following information on the partograph:
❖ 09.30 a.m. FHS120/min, Contractions 3/10 each 30 sec, Pulse80/min
❖ 10.00 a.m. FHS136/min, Contractions 3/10 each 30 sec, Pulse80/min
❖ 10.30 a.m. FHS 140/min, Contractions 3/10 each 35 sec, Pulse 88/min
❖ 11.00 a.m. FHS 130/min, Contractions 3/10 each 40 sec, Pulse 88/min
❖ 11.30 a.m. FHS136/min, Contractions 4/10 each 40 sec, Pulse84/min
❖ 12.00 noon FHS 140/min, Contractions 4/10 each 40 sec, Pulse 88/min
❖ 12.30 p.m. FHS 130/min, Contractions 4/10 each 45 sec, Pulse 88/min
Question:
What is the diagnosis?
What steps should be taken?
What advice should be given?
When do you expect to happen?
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Step 4:1.00 p.m.
❖ Cervix is fully dilated
❖ Contractions 4/10 each 45 sec
❖ FHS 140/min
❖ Amniotic fluid clear
❖ Pulse 90/min
❖ Blood pressure 100/70 mmHg
❖ Temp 37° C
Question:
How long was the first stage of labour?
How long was the second stage of labour?
Step 5:
Note: record on case sheet
❖ 1.20 p.m.: spontaneous delivery of a live female infant, weight. 2850 gm
3. Partograph Exercise 3.3
Step 1:
❖ Mrs Bharathy was admitted at 10.00 a.m. on 2.5.2010
❖ Membranes intact
❖ Gravida 1, para 0
❖ Hospital number 1443
Record the information above on the partograph, together with the following details:
Cervix is 4 cm dilated
❖ Contractions 2 in 10 minutes, each lasting 15sec
❖ FHS 140/min
❖ Membranes intact
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❖
Pulse 80 per minute
❖
Blood pressure 100/70 mmHg
❖ Temperature 36.2°C
Step 2: Plot the following information on the partograph:
❖
10.30 a.m. FHS 140/min, Contractions 2/10 each 15 sec, Pulse 90/min, membranes intact
❖
11.00 a.m. FHS 136/min, Contractions 2/10 each 15 sec. Pulse 88/min, membranes intact
❖
11.30 a.m. FHS 140/min, Contractions 2/10 each 20 sec, Pulse 84/min, membranes intact
❖
12.00 noon FHS 136/min, Contractions 2/10 each 15 sec, Pulse 88/min, membranes intact
❖
12.30 p.m. FHS 136/min, Contractions 1/10 each 15 sec, Pulse 90/min, membranes intact
❖
1.00 p.m. FHS 140/min, Contractions 1/10 each 15 sec. Pulse 88/min, membranes intact
❖
1.30 p.m. FHS 130/min, Contractions 1 /10 each 20 sec, Pulse 88/min, membranes intact
Step 3: Record the information above on the partograph, together with the following details:
At 2.00 p.m.
❖
Cervix is 4 cm dilated
❖ Contractions 2/10 each 20 sec
❖ FHS MO/mtn
❖ Membranes intact
❖
Pulse 90/min
❖
BP 120/80 mmHg
❖ Temperature 36.2°C
Questions
What is your diagnosis?
What action should be taken now?
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Key - Partograph exercise 3.1
Step 1: Have participants compare the recordings on their paragraphs
1. What is your diagnoses?
❖ Multi gravida in active labour
<♦ Maternal and fetal condition good
2. What advice should be given?
❖ To eat and drink fluids as tolerated
<♦ To practice breathing exercises to relax
3. Compare partograph plotted at step 2
❖ Normal progress of labour
<♦ Good maternal and fetal condition
❖ To inform if she has any discomfort
4. What action will you take?
♦♦♦ Be ready to coduct delivery
Key - Partograph exercise 3.2
Step 1
Q: What should be recorded on the partograph?
A: The woman is not in active labour. Record only the details of her history, i.e. first 4 bullets, not the
cervical dilatation.
Q: What steps should be taken?
A: Inform Suma of the findings and tell her what to expect; encourage her to ask questions; provide
comfort measures, hydration, nutrition.
Q: What advice should be given?
A: Advise Suma to assume position of choice but not to walk since membranes have ruptured; drink
plenty of fluids; eat as desired.
Q: What do you expect to find at 1.00 pm?
A: Progress to at least 8 cm dilatation.
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Step 2
Q: What should you now record on the partograph?
A: The woman is now in the active phase of labour. Plot the given information on the partograph.
Q: What steps should be taken?
A: Prepare for the birth.
Q: What advice should be given?
A: Advise Mrs Suma to push only when she has the urge to do so.
Q: What do you expect to happen next?
A: Spontaneous vertex delivery.
Steps 3 and 4:
Q. What is your diagnosis?
A. Normal progress of labour; good fetal and maternal condition
Q: What steps should be taken?
A: Routine monitoring of labour; reassure the woman; give her fluids to drink.
Q: What do you expect to happen next?
A. Looking at the progress, the woman is expected to have a normal delivery.
Q: How long was the active phase of the first stage of labour?
A: 5 hours.
Q: How long was the second stage of labour?
A: 20 minutes.
Key - Partograph exercise 3.3
Step 1
Have participants compare the recordings on their partographs with the partograph for Case 2.
Q. What is your diagnosis?
A. Mrs Bharathy is in active labour.
Q. What action will you take?
A. Inform of findings and what to expect; encourage her to ask questions; encourage her to move
around and to drink and eat as desired.
Step 2: Have participants compare the recordings on their paragraphs with the partograph for Case 2.
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Q. What is your diagnosis?
A. Failure to progress; poor uterine action; but good fetal and maternal condition.
Q: What action will you take?
A: Inform Mrs Bharathy of findings and what to expect, Reassure her; Encourage her to move about; give
her fluids to drink.
Step 3: Have participants compare the recordings on their paragraphs with the partograph
Q: What is your diagnosis?
A: Prolonged labour; with good fetal and maternal condition.
Q: What action should be taken now?
A: Refer the patient to a higher centre. See that her vital signs are normal, stabilize if needed and transfer
her to the centre urgently where augmentation or surgical intervention could be done.
Sample care study to use for mentoring session: Labour Case study 3.1
Instruction to mentor
Use this case study to help discus with staff nurses during'a planned group teaching
❖ You might have to make copies of them before your visit
❖ Review the case scenario before the session by yourself so that you are thorough with the possible
responses to questions.
❖ Review content in your mentoring manual and be thorough.
❖ Be sure to ask the District Program specialist if in doubt about any question.
❖ Read aloud the case scenario and facilitate the discussion.
Radha (wife of Gangaram), 26 years of age, third gravida, was admitted at 5:00 am on 11 June 2010. She
was full term and came with labour pains since 2:00 am. Her membranes ruptured at 4:00 am. She has two
children of the ages of 5 and 2 years. On admission, her cervix was dilated 2 cm.
Plot the following findings on the partograph
At 9:00 am:
❖ The cervix was dilated 5 cm.
❖ She had 3 contractions in 10 minutes, each lasting 30 seconds, the FHR was 120 beats per minute.
♦♦♦ The membranes had ruptured and the amniotic fluid was clear.
<♦ Her pulse was 80 per minute, blood pressure was 120/70 mmHg, and temperature was 36.8°C.
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Plot the following findings on the partograph.
<♦ 9:30 am: FHR 120/min, contractions 3/10 each 30 seconds, pulse 80/minute, amniotic fluid clear
❖ 10:00 am: FHR 136/min, contractions 3/10 each 35 seconds, pulse 80/minute, amniotic fluid clear
<♦ 10:30 am: FHR 140/min, contractions 3/10 each 40 seconds, pulse 88/minute, amniotic fluid clear
❖ 11:00 am: FHR 130/min, contractions 3/10 each 40 seconds, pulse 88/minute, amniotic fluid clear
<♦ 11:30 am: FHR 136/min, contractions 4/10 each 45 seconds, pulse 84/minute, amniotic fluid clear
❖ 12:00 noon: FHR 140/min, contractions 4/10 each 45 seconds, pulse 88/minute, amniotic fluid clear
❖ 12:30 pm: FHR 130/min, contractions 4/10 each 50 seconds, pulse 88/minute, amniotic fluid clear
Plot the following findings on the partograph.
At 1:00 pm:
❖ Cervix fully dilated
❖ Contractions 4/10 each 55 seconds
❖ FHR140/min
❖ Amniotic fluid clear
❖ Pulse 90/minute
❖ Blood pressurel 00/70 mmHg
<♦ Temperature 37° C
Questions:
1. What is your diagnosis after plotting the partograph at 1.00pm?
2. What can you predict about the outcome for this woman?
3. Why did you predict the above?
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Chapter 3
2. Labour case study 3.2
Rubina (wife of Zarif), age 26 years, was admitted at 11:00 am on 12 June 2009 in full term pregnancy with
labour pains since 4:00 am. Her membranes ruptured at 9:00 am. She has one child aged 3 years. She gave
birth to a stillborn baby 5 years back.
Plot the following findings on the partograph.
At 11:00 am:
❖ The cervix was dilated 4 cm.
<♦ She had 3 contractions in 10 minutes, each lasting less than 20 seconds.
❖ The FHR was 140 per minute.
❖ The membranes had ruptured and the amniotic fluid was clear.
❖
Her blood pressure was 100/70 mmHg.
<♦
Her temperature was 37° C.
❖
Her pulse was 80 per minute.
Plot the following findings on the partograph
<♦
11:30 am: FHR 130/min, contractions 3/10 each 35 seconds, pulse 88/minutes, amniotic fluid clear
❖
12:00 noon: FHR 136/min, contractions 3/10 each 40 second, pulse 90/minutes, amniotic fluid clear
12:30 pm: FHR 140/min, contractions 3/10 each 40 seconds, pulse 88/minutes, amniotic fluid clear
❖
1:00 pm: FHR 130/min, contractions 3/10 each 40 seconds, pulse 90/minutes, amniotic fluid clear
❖
1:30 pm: FHR 120/min, contractions 3/10 each 45 seconds, pulse 90/minutes, amniotic fluid clear
❖ 2:00 pm: FHR 120/min, contractions 3/10 each 45 seconds, pulse 88/minutes, amniotic fluid clear
❖ 2:30 pm: FHR 118/min, contractions 3/10 each 45 seconds, pulse 90/minutes, amniotic fluid clear
Plot the following findings on the partograph
At 3:00 pm:
❖ Cervix dilated 6 cm
❖ Contractions 4/10 each 45 seconds
❖
FHR 100/minute
❖ Amniotic fluid meconium stained
❖
Pulse 100/minute
❖
Blood pressure 120/80 mmHg
❖ Temperature 37.8°C
Questions:
1. What is your diagnosis after plotting the partograph at 3.00pm?
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2. What is the action you will take?
3. What initial management should be provided to the woman if she is referred?
3.6 Key Messages - Do's and Don'ts
First stage of labour
DO knowhow to tell the difference between true and false labour. True labou r consists of regular
uterine contractions that are getting stronger and closer together and result in cervical change.
-----------------—--------------- —-------------- —................... .... —... ...................................................
DO start the partograph when the woman is in active labour (4 cm dilated with regular
v
Do's
__
contractions). Using a partograph helps in the early identification of fetal, maternal and labour
0_______________________________ __________
DO NOT start a partograph in the latent phase of labour. Doing so can lead to unnecessary
obstetric interventions.
DO NOT start a partograph for a lady with complications. Complications need to be stabilized
and referred, not kept to labour at the PHC.
DO NOT use an oxytocic (like oxytocin) to induce or accelerate labour, as it is associated with a
high incident of rupture of the uterus.
DO NOT give epidosin to induce or accelerate labour. Women who are not having normal
progression of labour should not be kept at the PHC.
Don'ts DO NOT give an enema routinely to a woman in labour. This is unpleasant and not necessary.
DO NOT do a pelvic examination more often than every 4 hours as this increases the risk of intra
uterine infection (If there is something wrong with the fetal heart or maternal vital signs then
this rule does not apply). It is not necessary to shave the perineum before delivery.
______
DO NOT delay in referring any complication identified after initial stabilization.
DO NOT hit, slap or yell at the woman, or her family, in labour. This is unacceptable and
unprofessional behaviour and against the rights of the woman and her family.
DO NOT encourage the woman to push or bear down if the cervix is not fully dilated. It could
lead to injury of cervix, thereby swelling and obstructed labour.
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Second stage of labour
DO be prepared at all times for a delivery . Make sure all necessary equipment and
drugs are available and functional in the delivery room. Being prepared makes dealing
with routine delivery or complications easier.
DO continue to monitor vital signs and fetal heart rate during the .second stage as
complications can still occur during delivery.
Do's
DO encourage the women to push when the cervix is fully dilated and she feels a strong
urge to bear down and the perineum is beginning to bulge.
DO give an episiotomy only when required as it has been shown to cause increased
pain and blood loss. If required, give it as right medio-lateral episiotomy (RMLE).
DO provide perineal support during a contraction/pushing. This helps prevent tears.
DO place the baby over the mother's abdomen on a warm towel, dry and simultaneously
check if the baby is breathing or crying. Help the mother to give skin to skin contact
and cover the baby with a warm towel.
DO NOT encourage the woman to walk if the cervix is fully dilated since there is an
increased chance ofcord prolapse if the membranes have ruptured and the presenting
part is not engaged or the baby could be delivered suddenly. This could be a risk for
injury'to the ba by.
NOT encourage the woman to push actively until the fetal head is distending the
Don'ts DO
perineum and she feels the urge to push. Pushing before increases maternal efforts
and can lead to this tiredness
DO NOT apply fundal pressure while the woman is pushing since this can lead to
uterine rupture or other complications
Third stage of labour
DO check if there is a second live fetus in the uterus before starting AMTSL.
DO perform AMTSL routinely on all deliveries. This simple procedure is safe
and prevents postnatal hemorrhage. Remember AMTSL consists of three steps,
administration of oxytocin injection (IM), controlled cord traction and uterine massage.
Do's
DO routinely inspect the placenta for completeness. An incomplete placenta means
j retained placental fragments and will lead to PPH. It would require initial management
to stabilize the woman and referral for further management.
DO document all findings on the case sheet. Documentation shows that you have
performed all of the key procedures involved in provision of care in the third stage of
I labour.
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Chapters
DO NOT administer a uterotonic drug until after the baby is delivered, or if there is
concern that another baby is present and about to be delivered. This is because an
uterotonic drug makes the uterus contract which will also prevent the cervix from
opening enough to deliver the second baby.
Don'ts DO NOT apply cord traction (pull) without giving a uterotonic, without a contraction
and without applying counter traction (push) above the pubic symphysis with the
other hand. Doing so can lead to tearing off of the cord from the placenta (avulsion) or
turning the uterus inside out (inversion).
Fourth stage of labour
DO check the woman's vital signs every 15 minutes. Abnormal vital signs alert us to
I complications that need to be quickly recognized and acted on.
| DOchecktheuterinetoneandheightevery 15minutes. Increasing heightand/orafloppy
uterus is a red flag for postnatal hemorrhage and requires immediate management
DO check the amount of vaginal bleeding every 15 minutes. Increasing bleeding
| and/or blood on the pad are a red flag for postnatal hemorrhage and require
immediate management.
Do's
DO routinely estimate the amount of blood loss to help you become familiar with
recognizing the amount of blood loss that is normal from abnormal during a delivery.
I This will make is easier to recognize acute postnatal hemorrhage.
DO routinely inspect for and repair perineal tears. Identification of tears is important to
| decrease risk of bleeding and ensure proper repair.
DO keep the mother and newborn together. This encourages bonding and helps keep
the baby warm.
DO assist and encourage the mother to start immediate breastfeeding. It provides the
newborn with important calories and stimulates the release of oxytocin in the mother,
which helps keep the uterus hard, and contracted to prevent postnatal hemorrhage.
DO NOT leave the mother and baby unattended in the first hour after delivery.
Complications can arise quickly in this time frame and the mother and newborn need
to be closely watched.
DO NOT ignore any problem reported by the woman such as discomfort, inability to feed
baby, heavy bleeding, visual disturbances, feelings of uneasiness. Complications
Donis the
can arise at any time and complaints need to be listened to and acted upon quickly.
DO NOT refer any complication without stabilizing first. There is always something that
could be done at the PHC prior to referral. Taking the time to stabilize can mean the
difference between life and death.
Mentors'Manual Volume 2
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Chapter 4
5“r The Postpartum/Postnatal Period
Learning Objectives
At the end of this chapter you will
❖ Recall the importance of doing a relevant assessment of the women in the early postnatal period
I
❖ List and describe the relevance of the components of a good postnatal assessment
❖ Demonstrate how to do a comprehensive postnatal assessment and manage postnatal period
appropriately
❖ Demonstrate documentation of relevant early postnatal assessment and management of the
women admitted to the PHC, in the case sheet
❖ Demonstrate mentoring skills for doing a relevant early postnatal assessment and management of
the women presenting or admitted to the PHC
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4.1 Introduction
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The postnatal period is defined as the first 6 weeks following the delivery of the newborn. It could be
distinguished into early (the first 48 hours) and late (from after 48 hours to the end of 6 weeks) periods. The
postnatal period especially the early period is an important time since both mothers and their newborns
have a higher chance of developing complications. If complications are not identified and managed early,
it could lead to death.
Thus close attention needs to be given to the mother and newborn during this period by watching for any
abnormal vital signs and signs of complications while at the PHC or during home visits. It is also important
to make sure that the mother and her family have been counselled on possible danger signs in the mother
or newborn that she must report immediately for medical attention.
4.2 Components of Care in the Postnatal Period and their Importance
Maternal assessment
It is important to pay close attention to the condition of the woman. PHC staff can be alert as early as possible
about the presence of any complications and ensures that timely care is given.
Counseling on her care including maternal danger signs
It is best that women are counselled to stay in the PHC at least for 48 hours because complications most
often occur in this period. Most women however leave the PHC within 24 hours of giving birth. It is thus very
important that they and their families are made aware of the care they require, family planning methods and
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Skilled birth attendance care during labour, delivery and postnatal periods at 24/7 Primary Health Centres
of what is normal or abnormal for both themselves and their newborns in order to ensure that complications
are recognized early and delays in seeking care are avoided.
Medications and immunisation for newborn
During the early postnatal period the newborn baby would have to be administered Inj vitamin K, and
immunisations (BCG, oral polio and hepatitis B).
Postnatal assessment of woman and newborn
Specific assessments must be made during the first two hours after delivery to rule out any complications.
The case sheet helps to remember the assessments to be made.
4.3 Importance of Components of Postnatal Care
Maternal assessment:
Since the condition of the woman can change from one point in time to another it is important to examine
and ask the woman about the specific areas listed below, and this has to be done every sixth hourly for
the first two days if she is in the PHC. Asking the woman allows her to provide information about how she
is feeling. Her answers can also alert about a possible complication. If the woman gets discharged before
48 hours then she and her family need to be counselled specifically about the following.
❖ Bleeding PVthatis heavy
be a sign of postnatal hemorrhage or of uterine infection.
❖ Breastpain may be a sign of engorgement but can also indicate an infection. If present it is a flag to
examine the breasts and make sure no infection is present.
❖ /ereris a symptom of infection. If temperature is higher (more than 38°C), it is a reminder to check for
a focus of infection.
❖ Headache, blurred vision and vomiting are symptoms of PIH/ pre-eclampsia. These complaints should
serve as a red flag to recheck the blood pressure to see if it is normal or not.
❖ Lochia colour and odour. Normally following a delivery the woman will still have a small amount of
bleeding from the uterus - this is called lochia. At first it is red but then it becomes pale yellow and white.
Normally, it never has a bad smell. If there is a bad smell or greenish discharge it is a flag to the possibility
of an infection such as endometritis/ puerperal sepsis.
❖ Abdominalpain andperinealpain may be present after a normal delivery. The abdominal pain could
be due to the uterus contracting and the perineal pain may be due to a tear or episiotomy. However,
increasing abdominal and/or perineal pain is not normal and is a red flag for uterine or perineal
infection. The perineum should be examined to see if it is infected or not.
❖
Othercompiaints.V(\\s allows the woman to share any other concerns that she may have with you.
The woman should be examined
<♦ For bleeding per vagina: excess bleeding could be a sign of postpartum hemorrhage. It is a flag to
check if the uterus is contracted (feels like a cricket ball) or soft and tender. It is also a flag to check for
3rd or 4th degree tears or a torn blood vessel.
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❖ Checking uterine tone, height andtenderness. After delivery a normal uterus will feel hard and firm and
be at the level of or just below the umbilicus. Examining the uterus per abdomen tells us if the uterus is
remaining contracted or not. A uterus that is soft and boggy, or that is increasing in size (height above
the level of the umbilicus) is a red flag for postnatal hemorrhage due to uterine atony. A uterus that is
very tender is a red flag for endometritis/puerperal sepsis.
❖ Checking the episiotomy and/or tear If a tear or episiotomy is present it may become infected or
separated. Redness and pus indicate an infection, while a large gap between the edges indicates
separation of the wound.
❖
Vita!signs (bloodpressure, temperature, pulse, respiratoryrate). Assessment of vital signs is important
since abnormal vital signs could flag the possibility of a complication. For example
ZWrecould be high in case of fever, weaker barely palpable in the case of shock (infections, blood
loss) or irregular in case of heart disease.
An elevatedbloodpressured greater than 140/90mm Hg confirms PIH, while a low blood pressure
of less than 90/60mm Hg is suggestive of shock.
A high temperature, greater than 38°C indicates the presence of infection or sepsis. Low
temperatures could be seen in some cases of shock.
High respiratory rates (greater than 18-20/min) can indicate a respiratory problem such as infection
or clot.
Counselling on general care and maternal danger signs
General advice should focus on the care of both the mother and the newborn
❖ Maternalnutrition. Women in the postnatal period need to eat well and more than their usual amount,
when breastfeeding. They should be able to eat all types of foods such as cereals, pulses, meats, milk
products, fruits and vegetables. A good indication that she is getting enough of energy, body building
and protective foods is when her plate has food that has different natural colours. Eating well will make
her feel better.
❖ Familyplanning. Having babies too close together (less than than 2 years) increases risks for both the
woman and newborn. Information about various family planning methods should be shared in order to
help the woman delay and space childbirth or stop childbearing if she does not desire to have any more
children.
❖ Maternaldangersigns:~[he following areas should be discussed with the woman and her family
so that if they arise they do not delay seeking care from the PHC:
-0- Fever
Convulsions
*
Blurred vision / severe headache
<
Increased PV bleeding
Foul PV discharge or odour
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Breathing difficulty
Swollen / red / tender breasts
-0- Pain/difficulty in passing urine
Worsening abdominal pain
Worsening perineal pain
Counselling on medications and immunization for the newborn
Prior to discharge from the PHC the newborn should have been given the first doses of polio, TB (BCG) and
hepatitis B vaccine. These vaccinations help prevent infection and death in newborns.
Postnatal assessment of the woman and newborn
This section of the case sheet helps staff nurse to remember to assess / monitor and record important
information about the health of the mother and newborn in the postnatal period.
4.4 Requirements to Provide Postnatal Care
Equipments and supplies
Ensure that the following equipment is available at the PHC and in working condition:
❖ Blood pressure apparatus and stethoscope
❖ Thermometer
❖ Watch with seconds hand
❖ Disposable syringes and needles
❖ Polio vaccination
❖ TB vaccination
❖ Hepatitis B vaccination
❖ Family planning methods - IUD, oral contraceptives, injectables, condoms
Clinical skills
The clinical skills provides detailed information on how to perform each of these procedures and could be
used as a resource when mentoring.
Monitoring vital signs including PULSE, BLOOD PRESSURE,TEMPERATURE
Examination of the HEART AND LUNGS
Abdominal examination including UTERINE HEIGHT ANDTONE
Counselling skills for any SPECIFIC TOPIC (See details of each topic on Page)
Performing a NEWBORN ASSESSMENT
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4.5 Mentoring Skills
Sample for mentoring using a didactic group teaching method on important
elements of communication and counselling skills related to postnatal care
❖ Make an assessment of staff nurses ability to communicate effectively in the PHC either by direct
observation or an exit interview with women who are getting discharged.
<♦
Plan a session on communication and counselling skills based on the convenience of the staff nurses.
❖
Reaffirm the good or positive points present in the staff nurses.
❖
Have a 1 hour participatory session on the topic.
❖
Reinforce the points on good communication and counselling using the information given in the Table 4.1.
Table 4.1: Communication skills for counselling
What shows you are listening
What shows you are not listening
I
<♦ Facing the woman
Looking at the mother or suppdrt person while
s/he speaks
<♦ Nodding
❖
❖
Being calm
Being distracted
Not acknowledging what is being said
❖ Smiling dr frowning appropriately
❖
Looking away or around the room
<♦
Fidgeting
❖ Being patient
<* Writing notes, finding papers
<♦ Asking relevant questions
❖
❖
Interrupting
Not interrupting, permitting silence
Making eye contact
Counselling includes
Counselling does not include
I ♦♦♦ Establishing rapport with patients
❖ Telling patients what to do
i <♦ Having conversations with a purpose
<♦ Making decisions on behalf of patients
Listening attentively to patients
❖ Judging patients
I ❖ Helping patients tell their story
Interrogating patients
! <♦ Giving patients correct and appropriate information
❖
Blaming patients
i ♦** Helping patients make informed decisions
<♦
Preaching or lecturing to patients
|
Helping patients recognize and build on their
♦**
Making promises that you cannot keep
strengths
<♦
Imposing your own beliefs on patients
❖
Helping patients develop a positive attitude to life.
<♦ Arguing with patients.
❖
Reinforce to the group some important points that must be covered under counselling as given
in Table 4.2.
1
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Skilled birth attendance care during labour, delivery and postnatal periods at 24/7 Primary Health Centres
Table 4.2: Topics for counselling
7. Watch for dangersigns
2. Postnatal care andhygiene
Encourage on need for a support person for the first 48hours after the delivery.
<♦ Advise on hygiene
<
Have daily bath.
❖
Clean perineum daily and after passing stools/ urine
<
Change pads every 4-6 hours and more often if needed.
>
Wash cloth pads with soap and water and dry in the sun.
<
Wash hands before handling baby and especially after cleaning baby or going to toilet.
❖ Take enough rest and sleep.
❖ Avoid sexual intercourse till the perineal wounds have healed.
3. Nutrition
❖ Avoid restricting food and fluids.
Encourage the family members, such as the husband and mother/mother-in-law to ensure that
the woman eats well and avoids heavy physical work.
❖
Inform that during lactation the woman needs to eat more than her usual amount in a day. This
is not only because she needs to regain her strength, but also because, during the period of
exclusive breastfeeding, the baby relies solely on her for his/her nutritional requirements. Giving
one extra meal a day is one way to ensure that a lactating woman gets adequate nourishment.
♦♦♦
Include other important points such as
Give cereals like rice and wheat, milk and milk products such as curd, green leafy vegetables
and other vegetables, pulses, eggs and meat, including fish and poultry (if the woman is a
non-vegetarian), nuts (especially groundnuts), jaggery, fruits, etc.
Take locally available foods rich in iron such as green leafy vegetables, drumsticks, brinjal,
groundnuts and jaggery.
❖
Take enough of foods rich in fibre like fruit/green leafy vegetable to avoid constipation
Avoid taking tea or coffee, especially within 1 hour of a meal, as they have been shown to
interfere with the absorption of iron.
Take foods rich in proteins and vitamin C (e.g. lemon, amla, guava, oranges, etc.) as both help
in the absorption of iron.
♦♦♦
Inform them to choose foods based on the socioeconomic conditions, food habits and taste of
the individual.
<♦ Clarifywiththewomanandherfamilyonanyculturalhabitsaboutfood,andadviseappropriately.
Food taboos like restricting water, vegetable and fruit intake in the immediate postnatal period
and during lactation are usually stronger and more in number than during pregnancy.
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Chapter 4
4. /FA supplementation
❖ Take IFA tablet once a day for 3 months even if not anemic.
❖ Take IFA tablet twice a day for 3 months if anemic.
❖ Monitor and refer to the FRU, if Hb doesn't improve after 1 month of taking IFA.
5 Physicalactivity andpostnatalexercises
<♦ Inform the woman that she needs sufficient rest during the postnatal period to be able to regain
her strength.
❖ Involve the husband and family when providing advise on activity the woman can do.
Encourage her to avoid She any heavy work during the postnatal period but to take part in
physical activity such as post natal exercises to strengthen the abdominal and pelvic muscles .
6. Breastfeeding
❖ See section on breast feeding counselling Vol 3-Chapter 6.
7. Care ofthe newborn
❖ Refer to (Vol 3) - Chapter 3.
8. Familyplanning andcontraception
❖ Explain to the woman and her husband that, after birth, if she has sex and is not exclusively
breastfeeding, she could become pregnant as early as six weeks after delivery. Therefore, it is
important to start thinking early about what family planning method they will use.
❖ Discuss with the couple to abstain from having sexual intercourse during the first six weeks
postnatal, or longer if the perineal wounds have not healed by then.
❖ Ask about the couple's plans for more children. If they desire more, advise them that a gap of 3
to 5 years between pregnancies is healthier for the woman and the child. Inform her about the
following:
Family planning methods must be used 1 month after birth when she is exclusively breast feeding.
4*
Exclusive breast feeding alone might not guarantee prevention of pregnancy and it is
important to use another FP method simultaneously.
<♦ Discuss the advantages and disadvantages of the different family planning methods available to
them for birth spacing (or limiting, as the case may be) and help them make an informed choice
on what contraceptive method to adopt or accept.
9. Registration ofbirth
<♦ Advise them to get baby registered with the local panchayat. Birth registration certificate is a
legal document.The birth certificate is required for many purposes, e.g. admission into a school.
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4.6 Key Messages - Do's and Don'ts
DO monitor the woman and newborn closely in the first 48 hours postnatal. This is a
important time period where many women and newborns develop complications and die.
Being alert helps diagnose complications early and ensure prompt access to treatment.
DO always counsel the woman and her family on the maternal and newborn danger
signs. Knowing when to seek care avoids delays in treatment and can save lives.
DO check whether the woman wants a specific family planning method. Inform her that
Do's
it is best to wait till after 2years for the next child. Give her details of when she can start
family planning method and about the benefits and disadvantages of each method.
This will help her make an informed choice.
DO always counsel on general care, such as nutrition, family planning, immunization
and basic newborn care. Knowing how to stay healthy and prevent illness is important.
DO vaccinate the newborn against hepatitis, polio andTB (BCG) before discharging from
the PHC. Vaccinations prevent illness and save newborn lives.
DO NOT encourage myths about diet and newborn care practices.
DO NOT restrict foods for the woman. Encourage her to take all foods that she normally
Don'ts
would eat.
__________ ____
__
_
__ _____________
DO NOT miss counselling the significant family member (husband / mother in law/
mother) about family planning so that choice is made by the couple.
DO NOT assume that if a woman is exclusively breast feeding, she cannot get pregnant.
Mentors'Manual Volume 2
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Chapter 5
CM
U
Complications during Pregnancy,
Labour, Delivery and Postnatal
Period - Identification, Initial
Management and Referral
At the end of this chapter you will be able to
❖ Recall how to identify obstetric complications during pregnancy, labour and delivery and in the
postnatal period at the PHC
❖ Explain the appropriate initial management before referral for complications identified
❖ Demonstrate how to identify danger signs/ obstetric complications and provide the appropriate
initial management
❖ Demonstrate-documentation of complications>and appropriate initial management at the PHC
j
5.1 Introduction
Fifteen percent of all pregnancies will develop a complication. These complications can occur at any stage
during the pregnancy, labour and postnatal period. Of the complications that can occur, hemorrhage,
eclampsia and infections account for 60% of maternal deaths in India.This chapter deals with identification,
early management and referral of common obstetric complications at the level of 24/7 PHCs.
This chapter has seven sections, each section deals with one complication which may occur during
pregnancy, labour, delivery and postnatal period.The sections are arranged in the following order,
Section 5.A - Diagnosis, initial management and referral of complications- General principles
Section 5.B - Prolonged or obstructed labour and rupture of membranes morethan 12 hours duration
Section 5.C - Hypertensive disorders of pregnancy - PIH, pre - eclampsia, eclampsia
Section 5.D - Antepartum hemorrhage
Section 5.E - Infection or sepsis in pregnancy, labour and/or postnatal period
Section 5.F - Preterm labour/preterm or pre labour rupture of membranes
Section 5.G - Post partum hemorrhage
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SECTION 5.A
5. A. 1
Diagnosis, Initial Management and Referral of
Complications - General Principles
Components of Management of Complications
The maternal complications can be studied under the four broad headings:
❖
Diagnosis
❖
Initial management
❖
Referral to the nearest first referral unit (FRU)
❖
Role of case sheets for identification, initial management and referral
5.A.2 Importance of Components
Diagnosis of complications
❖ When a complication occurs it could be life threatening to both the woman and fetus.
❖ Three things must be done in a timely manner in order to minimize the risk of severe morbidity and/or
death of the woman and fetus/newborn:
The complication must be recognized quickly. Initial management must be started before referral.
A referral unit where care could be provided must be reached in a timely manner.
Within the referral facility appropriate, quality care must be delivered without delay.
❖
It is important to remain calm rather than being tense or rushed when making a referral. This will help
to make sure that the pregnant woman is stable. Otherwise it will take more time to provide the initial
management and could result in poor outcomes.
❖
Knowing how to recognize the common complications of pregnancy, labour and postnatal period could
improve quality of care and can help prevent maternal and fetal/neonatal morbidity and mortality.
Initial management of complications
❖ There is always something that could be done at the PHC level before referral.
This could help stabilize the woman before she reaches the nearest FRU. Both maternal and fetal
newborn outcomes are known to improve if complications are identified and initial management is
started promptly.
Referral to the FRU for complications
❖ The woman must be referred as soon as she has been stabilized to the nearest centre. Referral if delayed
could result in increased risk of maternal or neonatal mortality.
Role of using case sheets to identify complications
❖ The case sheets have been developed to help manage each of the specific complications.
❖ General principles apply to all the complication case sheets.
❖ The case sheets help arrive at a diagnosis by assessing specific parameters, provide instructions for the
initial steps of management and enables easy documentation while dealing with an emergency.
❖ They also act as a simple referral note that can accompany the woman, to document what has been
done prior to transfer.
Mentors' Manual Volume 2
5A.3 Requirements for Initial Management ofComplications during Labour, Delivery
and Postnatal Period
Equipments and supplies
In order to be able to perform the broad set of skills needed in management of all complications, ensure
that the following equipment and drugs are available and functional:
❖ Stethoscope
❖ Blood pressure apparatus
❖ Thermometer
❖ Fetoscope
❖ Watch with seconds needle
❖ IV cannulas/needles
❖ IV fluids (Normal Saline, Ringers Lactate)
❖ Foley's catheter and urine drainage bag
❖ Sterile gloves
❖ Disposable syringes
❖ Oxygen cylinders with flow meter
❖ Nasal prongs
❖ Inj Betamethasone and/or Dexamethasone
❖ Inj Oxytocin
❖ Inj Magnesium sulfate
❖ Antibiotics Injections - gentamycin, ampicillin, metronidazole, erythromicin
Clinical skills required for diagnosis and initial management of complications during labour, delivery and
post natal period
❖ Monitor and interpret VITAL SIGNS INCLUDING FETAL HEART RATE (See chapter 2 page 19)
❖ Insert IV LINE, ADMINISTER AND CALCULATE FLUID RATES (See Section 5G.3, page 117)
❖ Insert a FOLEY CATHETER (See chapter 5 page 95)
❖ Administer OXYGEN (See chapter 5 page 75)
❖ Administer CORTICOSTEROIDS FOR GESTATIONAL AGES BETWEEN 24-34 WEEKS (Seechapter 5 page 75)
❖ Accompany the woman DURING REFERRAL (See chapter 5 page 75)
5A.4 Mentoring Skills
Sample format to mentor staff on specific skills for management of complications
❖ During a mentoring visit, observe how staff are practicing specific skills required for management
of complications.
❖ Rememberthat there are certain clinical skills applicable to management of all complications (i.e. assessing
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Skilled birth attendance care during labour, delivery and postnatal periods at 24/7 Primary Health Centres
vital signs, starting an IV, administering and calculating fluid rates etc). The rationale for the inclusion of
the broader set of skills as basic clinical management principles is explained in the table below.
❖
Use the information in Table 5.1 when reinforcing to staff about the need to gain competence on
these skills.
❖
Demonstrate the procedures to the staff when the opportunity arises.
❖
Reaffirm positive steps taken by staff to complete the respective procedures.
Table 5.1: Clinical skill and their importance
Importance
Clinical skill
❖ Forany of the complications, detecting abnormalities in vital signs is
extremely important.
Know how to monitor and
interpret vital signs including
fetal heart rate
Know how to insert
intravenous (IV) line,
administer and calculate fluid
rates
Know how to insert a Foley's
catheter
Know how to administer
oxygen
Mentors' Manual Volume 2
❖ An abnormal vital sign or set of vital signs is often the first clue to
alert you to the problem and aid in diagnosis.
❖ They also provide important information as to how the mother and
fetus are responding to initial treatment and care. Since they can
change rapidly at any time they need to be monitored frequently.
❖
Many of th^complic^ions would require an IV to be started In order
to provide treatment (medications, fluids). This will also ensure that
intravenous access is in place if the mother's condition worsens.
<♦
Provision of fluid is. often an important element of initial care
(i.e. provides volume replacement in hemorrhage, replaces fluid
losses due to dehydration caused by fever, can help decrease fetal
tachycardia etc).
❖
Intravenous fluid can be given either to maintain the fluid balance or
to replace fluid loss (e.g. in the case of shock). Thus the reason why
intravenous fluid is given would help to decide how fast you give it.
Hence it important that the nurse knows how to calculate the drop
rate needed in order to correctly treat the complication (i.e. running
the fluid very slowly would not help with the treatment of shock).
❖ Inserting a Foley's catheter helps keep track of fluid status (intake
and output).
❖
It also helps prevent the formation of fistula from obstructed or
prolonged labour.
________
❖ The provision of oxygen helps improve both maternal and fetal
oxygenation. In complications such as severe bleeding, shock,
and obstructed labour the oxygen supply to the brain could be
lesser. If this is not corrected soon enough, it could have long term
complications for both the woman and baby.
Chapters
5
If any of the complications arise before term gestation (greaterthan 37
weeks) it is important to administer corticosteroids. Corticosteroids
could decrease neonatal mortality and morbidity since the chance
Know how to administer
of respiratory distress syndrome and necrotizing enterocolitis could
corticosteroids for gestational
be reduced.
ages between 24-34 weeks
♦♦♦ Thus all women in labour between 24 -34 weeks of gestation must
be given corticosteroids to help in the lung maturity.
Know who is to accompany
the woman during referral
Aside from the diagnosis of mild pregnancy induced hypertension, all
other complications require that a health care provider accompany
the mother during transfer. This is because the maternal and fetal
condition can deteriorate rapidly while on the way to the higher
facility. Delivery can also occur if the woman is in labour.
❖ Having a health care provider with the woman ensures that correct
monitoring and care is being provided during transport.
5A.5 Key Messages - Do's and Don'ts
DOusethecasesheetsXa arrive at the correct diagnosis by assessing specific parameters.
DO follow the initialsteps to stabilize andmanage prior to referrals given in the case
sheets.This will help you-provide necessary care in a timely manner and helps decrease
adverse outcomes.
Do's
DO document allactions taken on the case sheets. This serves as a simple referral note
that shows what emergency care the woman has already received.
DO know the common medications used to treat the complications. Being familiar with
the doses of the medications, routes and contraindications saves time and improves
quality of care.
DO NOTrush into making a diagnosis withoutproper history andassessments given in
the case sheet.Taking the time to do a quick, but proper assessment can help in giving
the correct treatment.
Don'ts
DO NOTdiagnose andrefer without first seeing that the woman is stable (wo m a n i s we 11
hydrated, not in shock, pulse palpable, bleeding controlled, no convulsions and the
woman will not deliver immediately, FHR good). There is always something that could
be done at the PHC first.
_____________________________
DO NOTgive medications that are not listed on the case sheet. These may cause harm
and make the situation worse.
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SECTION SB Prolonged or Obstructed Labour and Rupture of
Membranes more than 12 hours Duration
(See Complication Case Sheet A)
5B.1
Introduction
While the length of labour can vary, normal labour and delivery usually does not take more than 12 hours.
Once the woman has entered active labour, if 12 hours have passed without delivery this is a red flag to
think about obstructed or prolonged labour. Using the partograph can help you make this diagnosis earlier
since it helps to easily monitor the progress of labour and pick up any abnormalities. This is important to
decrease the risk of uterine rupture, hemorrhage, intra-uterine infection and sepsis, thus reduce risk of
maternal death, stillbirth, asphyxia and neonatal death.
The longer the membranes have been ruptured, with or without labour, the greater the risk of intra-uterine
infection and sepsis.This could increase the chance for both maternal and neonatal disability and/or death.
In both these situations it is important to recognize these complications early. This will help in providing
appropriate initial treatment and care before referral.
5B.2 Diagnosis and Provision of Initial Management for Obstructed or
Prolonged Labour
How to make a diagnosis ofprolongedor obstructediabour
❖ Criteria for correctly diagnosing prolonged and obstructed labour and rupture of membranes greater
than 12 hours are included in complication case sheet A and are listed below. A partograph should also
be used to aid in the diagnosis.
❖ Prolongediabour:(Any one sign should be present)
<
Plotted cervical dilatation line in the partograph is to the right of Line A at the four hour and eight
hour assessments
Contractions do not increase in frequency and duration
Cervix not dilated beyond 4 cm after 8 hrs of regular contractions
<
Cervix not dilating at least 1 cm an hour in active labour (regular contractions and initial PV of 3-4 cm)
No cervical change with repeat PV after 4 hours in active phase of labour
4^
Full dilation of cervix but no descent of fetal head despite maternal pushing efforts
Two contractions or less in 10 minutes lasting less than 40 seconds
❖
Obstructed labour:^ least two should be present)
-0-
Plotted cervical dilatation line in the partograph is to the right of Line A at the four hour and eight
hour assessments
No cervical change (secondary arrest) with repeat PV after 4 hours in active phase of labour
4*
Significant caput and moulding
4*
Cervix that is not well applied to presenting part
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Chapter 5
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Swollen, edematous cervix
Ballooning lower uterine segment
-0-
Formation of retraction band felt over abdomen
Fetal or maternal distress
Labour that is longer than 24 hours duration
❖ Rupture ofmembranes formore than 12 hours
Membranes have ruptured for more than 12 hours with or without contractions
❖
Leaking PV
Initialmanagement ofprolongedor obstructedlabour orprolongedrupture ofmembranes
morethan 12 hours
❖ Some common clinical skills/actions have already been explained in the general case sheet section
(section SA) and will not be repeated here. Only skills and initial management that are unique to
obstructed/prolonged labour will be presented.
❖ Keep the woman nilby mouth
❖
Treatment of prolonged/obstructed labour often involves cesarean section, which requires
anesthesia. Having a full stomach could increase the riskof complications from anesthesia. Thus if
the woman is kept nil by mouth, it would help to decrease this risk.
❖ Do notgive Injoxytocin
_
..
Oxytocin could increase the risk of uterine rupture or other complications and should be avoided
at the PHC level in cases of prolonged or obstructed labour.
-0-
It is important to transfer the woman as soon as possible to a higher level facility where she could
be assisted to deliver.
3. Administer the following antibiotics (ampicillin, gentamycin andmetronidazole)
Prolonged and obstructed labour and rupture of membranes for greater than 12 hours could
increase the risk of intra-uterine infection. Thus it is important to provide the initial dose of
antibiotics to help decrease this risk and/or to begin treating the infection if already present.
These three antibiotics are used because they cover the organisms most likely to be involved
in infection.
Do not administer other antibiotics unless the woman has a history of allergy to these antibiotics.
❖ Referral ofa woman to the FRU
Once the woman is stabilised it is important to transfer her along with a support person to the
nearest higher centre where appropriate services to further manage the complication are available
(specialist, cesarean section, etc).The centre must be informed, and the staff nurse must make sure
the doctor is available before transporting the woman to the facility.
Any delay in this process could contribute to poor prognosis of either one or both, i.e. the woman
and the fetus/newborn.
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Skilled birth attendance care during labour, delivery and postnatal periods at 24/7 Primary Health Centres
5B.3 Requirements for Initial Management of Prolonged or Obstructed Labour with
or without Rupture of Membranes
Equipments andsupplies
All equipment and drugs listed in the general skill set section (page #) plus the following:
❖
Cap or inj Ampicillin 1 gram orally or IV
❖
Inj Gentamicin 80 mg IM or IV
❖ Tab or inj Metronidazole 400 mg orally or 500 mg IV
Clinicalskii/s
In order to accurately diagnose and provide initial management for a woman with prolonged or obstructed
labour with or without rupture of membranes select skills are required.These skills should be reviewed and
focused on if there is any difficulty in performing them. These skills include:
❖
Monitor and interpret VITAL SIGNS INCLUDING FETAL HEART RATE (See chapter 2 page 19)
❖
Insert IV LINE, ADMINISTER AND CALCULATE FLUID RATES (See chapter 5 page 74)
❖
Insert a FOLEY CATHETER (See chapter 5 page 95)
❖
Administer OXYGEN (See chapter 5 page 75)
❖ Administer CORTICOSTEROIDS FOR GESTATIONAL AGES BETWEEN 24-34 WEEKS (See chapter 5 page 75)
❖
Accompany the woman DURING REFERRAL (See chapter 5 page 75)**
SB.4 Mentoring Skills
Sample case study to use for mentors
Case Study 5.1-Obstructedlabour
20 yrs. old Mrs. Lakshmi, primigravida is admitted with labour pains at 5 am.
Step 1 On examination at 5 am: (0 hour)
❖
Pulse 90/min, BP: 120/80 mmHg,Temp : 37.4°C
❖
P/A: 3 contractions for 15-20 sec/10 min, FHS: 140/min,
❖
P/V cervix 4 cm dilated, membranes present
7. IV/iaf will you do?
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Chapter 5
Step 2 At 9.00am (after 4 hours):
❖ Pulse 98/min, BP 120/70 mmHg,Temp : 38°C
❖ P/A: 3 contractions for 20-25 sec/10 min, FHS 126/min
❖ P/V: cervix 5 cm dilated, membranes present
7. Is the progress normal? (Note down the reasons for your answer).
2. What are the signs of obstructed labour?
3. How will you refer and what will you do before referring?
Key for Case Study 5.1 - Obstructed Labour
The purpose of the case study is to get participants to think through what steps need to be done
and why they would or would not do something. In all cases try to avoid directly giving the answers
- rather probe around the topic to see if the participants can come up with the responses. Review the
key points and answer any questions at the end of the case study.
Step 1. 20 yrs. old Mrs. Lakshmi, primigravida is admitted with labour pains at 5 am.
❖ On examination at 5 am: (0 hour)
❖ Pulse 90/min, BP: 120/80 mmHg, Temp : 37.4°C
❖ P/A: 3 contractions for 15-20 sec/10 min, FHS : 140/min,
<♦ P/V cervix 4 cm dilated, membranes present
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Skilled birth attendance care during labour, delivery and postnatal periods at 24/7 Primary Health Centres
1. What will you do?
Response: Monitor the progress of labour
Step 2. At 9.00 am (After 4 hours):
❖ Pulse 98/min, BP 120/70 mmHg,Temp 38°C
❖ P/A: 3 Contractions for 20-25 sec/10 min, FHS 126/min
❖ P/V: Cervix 5 cm dilated, membranes present
1. Is the progress normal?
Response: The cervical dilatation is not as expected, i.e., 1 cm/hr, hence the progress is delayed
2. What are the signs of obstructed labour?
Response
❖ Plotted cervical dilatation line in the partograph is to the right of Line A at the four hour and
eight hour assessments
❖ No cervical change (secondary arrest) with repeat PV after 4 hours in active phase of labour
❖ Significant caput and moulding
' '❖ Presenting part that ts not well applied to cervix
❖ Swollen, edematous cervix
❖ Ballooning lower uterine segment
❖ Formation of retraction band felt over abdomen
❖ Fetal or maternal distress (Woman: tachycardia, signs of dehydration & fever, baby - fetal distress)
❖ Labour that is longer than 24 hours duration
3. How will you refer and what will you do before refering?
Do the following
❖ Talk to the relatives about the condition of the woman ~
❖ Call and determine the nearest higher centre (FRU) where a LSCS could be done if necessary
<* Ensure specialist is available at FRU before transporting woman
❖ Arrange transport
❖ Keep the woman NPO
❖ Do not give oxytocin
♦♦♦ Insert 16-18 gauge IV and provide IV normal saline or ringer lactate @ 30 drops/min
♦♦♦ Insert Foley's catheter
❖ Start oxygen
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Chapter 5
❖ Give all the three following antibiotics
*
Cap or inj Ampicillin 1 gm either Oral or IV
Tab or inj Metronidazole either 400mg Oral or 500mg IV
Inj Gentamicin 80mg either IM or IV
While in transport
❖ Keep the woman in left lateral position
Continue fluid and carry extra bottles to last till she reaches the higher facility / FRU
Provide oxygen
Keep a delivery set and essential drugs handy
❖ Ensure that staff nurse accompanies the woman
Carry relevant documents
❖ Take the plotted partograph
❖ Take the filled up complication case sheet A
5B.4 Key Messages - Do's and Don'ts
DO start the initial management and stabilize prior to referral. Doing so
prevents delays in receiving appropriate care and helps decrease the risk
of adverse outcomes in the woman and fetus.
DO document all findings and treatment accurately in the case sheet.
This would act as a referral note and would help with communication
and follow up.
DO accompany the woman during referral. Changes in the status of the
Do's
maternal and fetal condition can happen quickly. Accompanying the
woman would ensure that appropriate monitoring and care are also
being delivered during transport.
DO be prepared for complications that may arise during transport. Since
rapid changes in maternal (severe abdominal pain, bleeding PV could
be early signs of a ruptured uterus) and fetal status (no fetal heart
sounds) can occur, it is important to be prepared and equipped to deal
with these issues as they arise (i.e. have extra bottles of fluid, oxygen for
the woman etc).
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Skilled birth attendance care during labour, delivery and postnatal periods at 24/7 Primary Health Centres
DO NOT give oxytocin. This can increase the risk of uterine rupture.
DO NOTgive the woman anything orally prior to referral. If she does need
a cesarean section this can increase her risk of anesthetic complications.
Don'ts
DO NOT try to deliver the baby if prolonged or obstructed labour is
diagnosed at the PHC. Women with prolonged and obstructed labour or
rupture of membranes more than 12 hours need to be referred as soon as
possible. This can reduce the risk of adverse maternal, fetal and neonatal
outcomes.
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Chapter 5
Section 5C Hypertensive Disorders of Pregnancy: PregnancyInduced Hypertension, Pre-eclampsia & Eclampsia
(See Complication Case Sheet B)
5C.1
Introduction
Hypertensive disorders of pregnancy include pregnancy induced hypertension (PIH), pre-eclampsia and
eclampsia. Their presentation can range from mildly elevated blood pressure without any symptoms to
sudden onset of full seizures/fits any time in pregnancy after 20 weeks gestation, intrapartum and in the
first 6 weeks postnatal.The exact reason as to why this happens in women during pregnancy is not straight
forward and many factors appear to play a role. What is certain is that this group of diseases causes serious
illness in both the woman and fetus that can lead to increased risk of morbidity (heart failure, placental
abruption, renal failure, liver failure, cerebral swelling and bleeding in the woman; intrauterine growth
restriction and preterm birth in the fetus) and mortality for both the woman and fetus.
5C2 Diagnosis and Provision of Initial Management for PIH / Preedapmsia /
Eclampsia and its Importance
How to make a diagnosis ofhypertensive disorders in pregnancy PIH, pre-eclampsia, eclampsia
Early detection is very important to manage pregnancy-induced hypertension and prevent convulsions.
So it js important that a nurse
.
* Checks vital signs (temperature, pulse, respiration and BP) as part of the initial assessment of a
woman who comes with labour pains to the PHC.
Check the antenatal Thayi card to see if the BP has been checked before and if a diagnosis has
already been made. This will save time.
Check urine for presence of protein using dipstick method: As hypertensive disease in pregnancy
worsens, the woman begins to leak protein into the urine from the kidneys. This is important
to know since it can help to correctly distinguish between the different types of hypertensive
disorders and determine the severity of disease. For example, the presence of proteinuria changes
the diagnosis from pregnancy-induced hypertension to pre-eclampsia. How much protein is in
the urine determines if it is severe disease or not. A woman with eclampsia may or may not have
protein in the urine.
Specific findings to diagnose PIH, pre-eclampsia and eclampsia are given in Table 5.2.
Skilled birth attendance care during labour, delivery and postnatal periods at 24/7 Primary Health Centres
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ft
Table 5.2 Classification of PIH/ pre eclampsia and eclampsia
Assess if following are present to confirm the diagnosis (refer to the complication case sheet B)
DIAGNOSIS
Gestational age
Blood pressure (mmHg)
Proteinuria
Convulsions
Mild PIH
More’than 20
weeks
BP more than or
equal 140/90 and less than
or equal 160/110
NO
NO
Severe PIH
More than 20
weeks
BP more than or
equal160/110
NO
NO
Mild pre-eclampsia
More than 20
weeks
BP more than or
equal 140/90 and
less than or equal 160/110
YES
NO
Severe pre-eclampsia
More than 20
weeks
BP more than or
equal160/110
YES
NO
More than 20
weeks
BP more than or
equal 140/90
YES
YES
-
.X «
Eclampsia
..
.J
Accurate assessment and correct diagnosis is very important for initial management of pregnancy
induced hypertension, pre-eclampsia and eclampsia. Criteria for correctly diagnosing these are
| included in complication case sheet B
Start initialmanagement ofthe complication
Management will be different for pregnancy induced hypertension, pre-eclampsia and eclampsia and
is also based on how severe is the disease.
❖ For severe disease, immediate delivery within 12- 24 hours is the definitive treatment.
❖ But at the time of diagnosis, prior to delivery, there are things a nurse can do to help prevent
complications, such as giving antihypertensive and anticonvulsant medication.
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❖ Administer antihypertensives (nifedipine orally or hydralazine IV) in severe PIH and severe
pre-eclampsia (BP more than 160/110 mmHg)
❖
In severe cases where the blood pressure is equal to or greater than 160/110 mmHg the woman is
at risk of having a stroke.
If the first dose of medication to reduce the BP (antihypertensive) is given it will help to lower the
blood pressure and prevent stroke from happening.
Oral nifedipine and IV hydralazine are the preferred medications. They act quickly and are safe for
the woman and baby.
These are the only drugs that should be used.
Sublingual nifedipine (giving it under the tongue) must never be used since it lowers the blood
pressure too quickly, leading to dizziness and fainting.
❖ Administer anticonvulsants
A woman who has a seizure (eclampsia) needs medication to help stop the seizure and to prevent
more seizures from happening.
-$■
A woman who has severe pre-eclampsia also needs medication to prevent seizures from occurring.
<
Inj Magnesium sulfate is the drug of choice and should be the first choice of anticonvulsant drugs
in these cases.
This is because magnesium sulfate acts better than others to stop and prevent seizures in
pregnancy, labour and postnatal. Thus it can reduce maternal mortality.
*
It is given as an intramuscular injection because this route is easier to give a woman who has a
seizure or when it is not possible to start an IV.
4-
inj Diazepam is the next drug of choice if magnesium sulfate is not available. It is the second choice
because it is not so good at stopping and preventing seizures in pregnancy.
It can be given rectally as the lining of the rectum quickly absorbs the medication and it thus the
onset of action is fast.
♦♦♦ Monitor deep tendon reflexes, urine output, respiratory rate for magnesium sulfate toxicity
Magnesium sulfate can cause toxicity if the woman is not able to properly excrete it from her body
(this is done via the kidneys).
■$-
So it is important to check deep tendon reflexes, urine output and respiratory rate as any
abnormality in these could mean to stop giving any more doses. Abnormalities include
4-
Urine output that is less than 30 ml per hour over 4 hours,
Respiratory rate less than 16 per minute,
Loss of patellar deep tendon reflexes.
Referral to the FRU
Refer the woman as soon as she has been stabilised and make sure there is someone to accompany her.
See that all the documents are completely filled as this will help in management at the referral centre.
Skilled birth attendance care during labour, delivery and postnatal periods at 24/7 Primary Health Centres
Skilled birth attendance care during labour, delivery and postnatal periods at 24/7 Primary Health Centres
5C3 Requirements for Diagnosis and Management of Hypertensive Disorders in
Pregnancy
Equipments andsupplies
In addition to the equipment and drugs listed in the general skill set (Section 5A Page 73), in order to be
able to perform the specific set of skills needed to manage this complication ensure that the following
drugs and equipment are available and functional:
❖
Inj magnesium sulfate 10mg
❖
Inj diazepam 20mg
❖ Tab nifidipine 5mg orally
❖ Inj hydralizine 5 mg IV
❖
Knee hammer to elicit deep tendon reflexes
❖
Urinary catheter if catherisation is required
❖ Measuring bag for urine output
Clinicalskills
Administration of MAGNESIUM SULFATE INTRAMUSCULARLY
1. Give inj magnesium sulfate in case of severe pre-eclampsia and eclampsia. Give the first dose (only one
dose) of magnesium sulfate injection (a total of 10gm).
2. Collect all articles required for an IM injection such as needle, syringe, cotton swab with spirit, puncture
proof container to discard the needle.
3. Wash hands thoroughly.
4. Take a sterile 10 cc syringe and 22 gauge needle.
5. Break 5 ampoules and fill the syringe with the inj magnesium sulfate solution, ampoule by ampoule (10
ml in all).
6. Take care not to suck in air bubbles while filling the syringe. (Each ampoule has 2 ml of magnesium
sulfate 50% w/v, 1 gm in 2 ml).
7. Identify the upper outer quadrant of the hip, clean
it with a spirit swab and let the area dry.
8. Administer the 10 ml (5 gm) injection (deep
Poster^
ihacspkx?
intramuscular) in the upper outer quadrant in one
■
buttock, slowly. This site is chosen since the amount
to be injected is large and this muscle is best.
Greater
r
Divide the buttocks into 4 quadrants.
Draw an imaginary line from the anterior
Scetc
rxxv©
superior iliac spine to the sacrum. Feel for the
highest portion of the pelvis crest.
Draw a vertical line to divide the previous line
into half.
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Figure 5.1: Site for IM injectionfgluteal site)
■
■■■
t.
SI
•
it
Draw an imaginary line from the greater trochanter of the femur to the posterior iliac spine
(see Figure 5.1). The site identified must be above this line. Then you are sure of avoiding the sciatic
nerve.
Administer the injection in the upper outer quadrant.
9.
Tell the woman she will feel warm while the injection is being given.
10. Repeat the procedure with the same dose (i.e. 5 ampoules—10 ml/5 gm) in the other buttock.
11. Dispose of the syringe in a puncture-proof container (if disposable).
12. Wash hands.
MonitoringforMAGNESIUMSULFATE TOXICITY
1. Check the respiratory rate after giving inj magnesium sulfate.
2. Check the patellar deep tendon reflexes.
3. If respiratory rate is less than 16/minute, patellar deep tendon reflex is absent or urine output
is less than 30 ml/hour, it indicates MgSO4toxicity. Then give inj calcium gluconate Igm IV over
10 minutes
Checking PATELLAR DEEP TENDONREFLEXES
1. Get all articles required such as knee hammer/ reflex hammer.
2. Wash hands.
..
-
3. Tell the woman to lie down, relax and inform what will be done. Show her the knee hammer but don't
tell the name as this can cause anxiety.
4. Place arm under one knee and lift it from the bed while supporting hand on the woman's other knee.
Lift up both knees together if desired. Locate the patellar tendon between the tibial tubercle and the
lower border of the patella (just below the knee cap see Figure 5.2).
5. Swing the patellar hammer so that it falls onto the patellar tendon.
Scinalcora
WnirilRoot
Motor Norre (Efferent?
Dorsal Root
luadrlceps (muscle)
SensoryNerra (MSejenQ •
’atelia
■W'
:•->■
If
1
Femur
Leg movement
Fig. 5.2 How to check patellar reflex
3
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Chapter 5
http://www.cetl.org.uk/learning/skills_sheets/Tendon-Reflexes-KJ.pdf
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Skilled birth attendance care during labour, delivery and postnatal periods at 24/7 Primary Health Centres
6. At the same time watch for a contraction in the quadriceps muscle. Note the strength of the reflex as
given below:
❖ 0: absent reflex (abnormal)
❖ 1 +: trace/seen only with reinforcement
❖ 2+: normal
❖ 3+: brisk
❖ 4+: non sustained clonus (i.e., repetitive vibratory movements, abnormal)
❖ 5+: sustained clonus (abnormal)
Estimation ofURiNE OUTPUT
<♦ Expected urine output for an adult is more than 1 ml/kg/hour. Thus on an average 30ml/hour of urine
output can be considered as normal.
5C.4: Mentoring Skills
Sample ofcase study for use when mentoring
Case Study - PIH/pre-edampsia/edampsia
Case study5.2-PartA
Mrs. Basanthy is a 16 year old gravida 1 par£ 0 referred to your PHC from the'*ANM at the Sub-Centre. She
reports that she was told she had "high blood pressure" and to come to the PHC for further assessment. A
review of her records shows that she had three antenatal visits this pregnancy and that all findings were within
normal limits, except for the last visit. At her last visit, her blood pressure was 140/90 mmHg. Her urine was
negative for protein. The fetal heart sounds were normal, the fetus was active and uterine size was consistent
with dates. She is currently 37 weeks gestational age.
1
What do you think about the blood pressure measurement of 140/90? Is this normal or abnormal?
2 Why is it important to know that the urine was negative for protein?
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Chapter 5
3
Based on this information from her last visit of a blood pressure of 140/90 mmHg and no proteinuria
what would your diagnosis have been then?
4. Now, at her visit with you, what would you like to include on your initial history when talking with Mrs. Basanthy
and why?
5
6
What would you like to do on physical examination and why?
What screening procedures/laboratory tests will you include (ifavailable) in your assessment ofher, and
why?
Case study5.2-Part B:
You have completed your assessment of Mrs. Basanthy, and your main findings include the following:
❖ History: Mrs. Basanthy is complaining of severe headache, and blurred vision. She says she does not have
any upper abdominal pain, convulsions or loss of consciousness. She reports normal fetal movement.
❖ Physical Examination: Mrs. Basanthy's blood pressure is 170/120mmHg, and she has 4+ proteinuria.
❖ The fetus is active and fetal heart rate is 136 per minute. Uterine size is consistent with dates.
7. Based on these findings, what is Mrs. Basanthy's diagnosis (problem/need), and why?
Skilled birth attendance care during labour, delivery and postnatal periods at 24/7 Primary Health Centres
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|
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Skilled birth attendance care during labour, delivery and postnatal periods at 24/7 Primary Health Centres
Case study 5.2-Part C:
8. Based on your diagnosis (problem/need identification), what is your plan of care for Mrs. B., and why?
9. If Mrs. Basanthy had presented with convulsions, what would your diagnosis have been?
10. What would your plan of care be for Mrs. Basanthy if she was having convulsions?
Key for Case Study 5.2
I'... -
.
I Case study 5.2: PartA
Mrs. Basanthy is a 16 year old gravid 1 para 0 referred to your PHC from the ANM at the Sub-Centre. She
reports that at that visit she was told she had "high blood pressure" and to come to the PHC for further
assessment. A review of her records shows that she has had three antenatal visits this pregnancy and
that before this last visit all findings were within normal limits. At her last visit, it was found that her blood
pressure was 140/90 mmHg. Her urine was negative for protein.The fetal heart sounds were normal, the
fetus was active and uterine size was consistent with dates. She is currently 37 weeks gestational age.
7. What do you think about the blood pressure measurement of 140/90? Is this normal or abnormzal?
Answer:
It is abnormal. Discuss normal blood pressure in pregnancy. Blood pressure of greater than
or equal to 140/90 mmHg after 20 weeks gestational age is not normal and is consistent
with the diagnosis of pregnancy induced hypertension.
2. Why is it important to know that the urine was negative for protein ?
Answer:
The absence of protein in the urine indicates that the patient only has pregnancy
induced hypertension and not pre-eclampsia. If there was protein in the urine with a
blood pressure of greater than or equal to 140/90 mmHg after 20 weeks then the woman
would have pre-eclampsia. Whenever someone presents with high blood pressure it is
absolutely essential to determine if there is protein in the urine or not as this changes
your diagnosis and management.
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3. Based on this information from her last visit of a blood pressure of 140/90 mm Hg and no proteinuria
what would your diagnosis have been then?
Answer:
Mrs. Basanthy's signs and symptoms: diastolic blood pressure 90-110 mmHg after 20 weeks
gestation and no proteinuria are consistent with pregnancy induced hypertension.
4. Now, at her visit with you, what would you like to include on your initial history when talking with
Mrs. Basanthyand why?
Answer:
The following should be discussed and if they do not mention all steps probe by asking, "Is
there anything else you would want to ask, why or why not?"
❖ Mrs. Basanthy should be greeted respectfully and with kindness.This helps build rapport with her.
<♦ She should be told what is going to be done and listened to carefully. In addition, her questions
should be answered in a calm and reassuring manner. This reassures the patient and also helps
build rapport.
Ask specifically about the following: has she had headache, blurred vision, upper abdominal pain or
fits/seizures other problems since her last clinic visit. These are important questions to ask because
they are symptoms of hypertensive disorders of pregnancy. They area also the danger signs that
should be discussed with all pregnant women as indications to seek care immediately.
<♦
She should be asked whether fetal activity has changed since her last visit. This is important to ask .
about because it provides an indication of fetal well being.
5. What would you like to do on physical examination and why?
Answer:
The following should be discussed and if they do not mention all steps probe by asking, "Is
there anything else you would want to do, why or why not?"
Blood pressure should be measured. Blood pressure greater than or equal to 140/90 after 20 weeks
gestational age is indicative of pregnancy induced hypertension. If protein is present in the urine
then it is indicative or pre-eclampsia.
An abdominal examination should be done to check fetal growth and to listen for fetal heart sounds.
This is an indication of fetal wellbeing (in cases of pre-eclampsia/eclampsia reduced placental
function may lead to low birthweight; there is an increased risk of hypoxia in both the antenatal and
intrapartum periods, and an increased riskof abruptio placentae).
6. What screening procedures/laboratory tests will you include (if available) in your assessment of
Mrs. Basanthy, and why?
Answer:
Urine should be checked for protein, since the presence of protein in the urine changes the
diagnosis from pregnancy induced hypertension to pre-eclampsia.
88
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■
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Chapter 5
■
mHI
9. If Mrs. Basanthy had presented with convulsions what would your diagnosis have been?
Answer:
9
Eclampsia. All seizures in a pregnant woman from after 20 weeks up until 6 weeks postnatal
9
are eclampsia until proven otherwise.
10. What would your plan of care be for Mrs. Basanthy if she was having convulsions?
Answer:
The following, should be mentioned. In discussion explain why. If they do not mention all
steps probe by asking, "Is there anything else you would want to do, why or why not?
❖ Do not leave the woman by herself. Being with her helps to prevent from fall or injury.
❖ Protect the woman from fall or injury, but do not restrain her. Restraining her can actually
harm her.
❖
Ensure a clear airway and breathing. If the woman is unconscious, keep her on her back with
her arms at the side; tilt her head backwards and lift her chin to open the airway.
❖ Turn her to a left lateral position after the convulsion. Keep the woman in this position
throughout transportation.
❖ Keep a mouth gag between the upper and lower jaw to prevent tongue bite. (Do not attempt
to do this during a convulsion).
Measure the BP of the woman. Maintain a record of these. Knowing the blood pressure will let
you know if the mother will also need a dose of antihypertensive medications. If the systolic
is greater than 160 mmHg or the diastolic greater than 110 mmHg then she will need an
antihypertensive. This prevents against the risk of her having a stroke.
<♦ Give the first dose of inj magnesium sulfate. Give 10 ml deep IM in each buttock (a total
of 20 ml). It is important to ensure that this is given deep because otherwise it can lead to
the formation of an abscess at the injection site. Magnesium sulfate is the preferred drug of
choice for treating seizures in pregnancy.
Start an IV infusion, and give IV fluids slowly @ 30 drops/minute and insert a Foley's catheter.
This will prevent the woman from becoming dehydrated, allow you to monitor urine output
(which can decrease significantly in eclamptic women) and provides IV access if you need
additional medication.
<* Tranquilizers and sedative should NOT be given.There is no benefit to given these - they may
actually harm the woman and her baby.
❖
Immediately arrange to refer the woman to an FRU. Eclampsia is a life threatening condition
for the both the woman and baby and she needs to be transferred to a centre where delivery
can be conducted early as possible.
❖
Ensure that the woman reaches the referral centre within 2 hours of receiving the first dose
of magnesium sulfate.This is because women with eclampsia need to be delivered within 12
hours from the onset of the seizure.
❖ She should not be sent alone. She should be transported via ambulance. This is because this
is a life threatening condition and she needs to have help with her.
Skilled birth attendance care during labour, delivery and postnatal periods at 24/7 Primary Health Centres
*
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Skilled birth attendance care during labour, delivery and postnatal periods at 24/7 Primary Health Centres
11.If magnesium sulfate is not available in your PHC what other drug would you use for treatment
of seizures in pregnancy and how would you give it?
|
Answer: Diazepam 20 mg rectally in 10 ml syringe. This is second line and should be given only if
magnesium sulfate is not available. Magnesium sulfate is the preferred drug since it is better
|
|
and stopping seizures in and preventing them in cases of pre-eclampsia and eclampsia.
Keypoints to review at the endofthe case study5.2
Severe pre-eclampsia and eclampsia are life threatening conditions that need to
be recognized and treated immediately.
<♦ Blood pressure greater than or equal to 140/90 mmHg in pregnancy is not normal.
All women with increased blood pressure in pregnancy should have their urine
checked for the presence of protein.
♦** Blood pressure greater or equal to 160/110 mmHg requires a dose of
antihypertensive before referral.
❖ Women with severe pre-eclampsia and eclampsia need to be stabilized before
being referred to the FRU.
<♦ Women with severe pre-eclampsia need a prophylactic dose of magnesium
sulfate prior to transfer to the FRU.This helps prevent seizures.
Magnesium sulfate is the drug of choice to treat seizures in pregnant women.
<♦ Tranquilizers and /or sedatives should NOT be given to women with, pregnancy
induced hypertension, severe- pre-eclampsia or eclampsia.
♦♦♦ DO NOT leave a woman who has a seizure alone.
5G5 Key Messages - Do's and Don'ts
DO know the normal (120/80 mmHg) and abnormal values for blood pressure in
pregnancy. This is important in order to be able to correctly diagnose hypertensive
disorders of pregnancy. A blood pressure of 140/90 is never normal.
Do's
DO always check urine forprotein (normalmeans nilprotein). This is vital for correct
diagnosis and management. The presence of proteinuria changes the diagnosis from
pregnancy-induced hypertension to pre-eclampsia.
DO actively treat and refer all women with hypertensive disease. Delays in treatment
and care are what lead to adverse outcomes, including convulsions and death.
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DO treat allpregnant and postnatal women who have seizures as eclampsia until
proven otherwise.
\----------------------------------------------------------------------------------------------------------------DO give nifedipine orally or IV hydralazine if the diastolic bloodpressure is greater
i than IIOmmHg. These are the first drugs of choice. They help prevents stroke and
cerebral hemorrhage
DO know that injection magnesium sulfate is the drug of choice forpreventing and
treating convulsions in severe pre-eclampsia and eclampsia. All women with severe
pre-eclampsia and eclampsia should be given this drug before referral.
Do's
DO closely monitor the woman for signs oftoxicity. If signs of toxicity are present do
not give additional doses of magnesium sulfate.
i DO Insert a Foley's catheter and intravenous access. F Foley catheter helps to know
what the urine output and IV fluids help keep the woman hydrated and will ensure an
access to give medications.
DO give the first dose ofcorticosteroidifthe gestationalage is between 24-34 weeks.
This decreases neonatal morbidity and mortality.
j__________________________________________________________________________
I DO accompany the woman during referral. Changes in the status of the maternal
and fetal condition can happen quickly. Accompanying the woman ensures that
appropriate monitoring and care will be delivered during transport.
DONOTgive methyi-ergometrine in women with hypertensive disorders ofpregnancy.
It increases the risk of convulsions and cerebrovascular accidents (stroke).
DO NOT try to deliver the baby at the PHC even in case ofmild PIH unless delivery is
imminent. Delays in treatment and care are what lead to poor outcomes, including
convulsions and death.
DO NOT diagnose and refer without stabilizing first. There is always something that
could be done at the PHC first.
Don'ts
DO NOTuse diazepam to treat convulsions unless magnesium sulfate is unavailable.
Magnesium sulfate is the first choice for treatment and prevention of convulsions
DO NOTgive nifedipine sublingually (under the tongue). This can cause the blood
pressure to drop much too quickly.
DO NOT leave the woman alone. Severe pre-eclampsia and eclampsia are life
threatening conditions and mothers must always have someone with her.
DO NOTgive an antihypertensive unless the diasto/ic bloodpressure is 710 mmHg. If
the diastolic is below 110 mm Hg giving a medication can make the blood pressure
too low.
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Skilled birth attendance care during labour, delivery and postnatal periods at 24/7 Primary Health Centres
Section 5D Antepartum Hemorrhage
(See Complication Case Sheet C)
5D.1
Introduction
Vaginal bleeding anytime after 20 weeks of pregnancy is called antepartum hemorrhage (APH).The most
serious causes are placenta praevia (placenta lying at or near the cervix), abruptio placentae (separation
of the placenta before the birth of the fetus) or a ruptured uterus. Since these conditions could be life
threatening for the woman and fetus it is important to diagnose the cause of bleeding so as to initiate
the right initial management. Criteria for correctly diagnosing the different causes of antepartum
hemorrhage are included in complication case sheet C
5D.2: Diagnosis and Provision of Initial Management for APH
IdentifyAPH early
<♦ The commonest causes of APH include placenta previa, abruption placenta and ruptured uterus. See
complication case sheet C-APH
❖ If diagnosed early, the woman could be started on IV fluids immediately and this could prevent shock
❖ For severe disease, delivery within 12- 24 hours is the definitive treatment.
❖ It is important to look for specific signs and symptoms in the woman who presents with bleeding after
20 weeks. This will help to differentiate between the causes and could determine the management for
the woman. The signs and symptoms of the major causes of APH are given in Table 5.3
Table 5.3: The signs and symptoms of the major causes of APH
Placenta praevia
Abruptio placenta
❖ No abdominal pain (the woman is pain free <* Abdominal pain (if contractions are present and
the pain is present in between contractions)
or if having contractions has no pain between
contractions)
❖ Bleeding from the vagina present and in past
Relaxed uterus on palpation / uterus irritable
*:* Tense dr tender uterus on palpation
<♦ Bleeding from the vagina (if concealed there
may be no bleeding seen)
Remember
APH is an emergency and has high chance of making the woman/fetus more sick or
causing death of both. Act promptly
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Start initialmanagement
❖ Whenever there is bleeding it is important to determine the extent of blood loss.
❖ Assess for shock whether present or not
-0- Significant blood loss leads to shock. The most important aspect of managing APH is to assess if
shock is present or not.
-0- If shock is suspected, start an IV line and replace fluids with IV fluid or and blood transfusion.
Elevate legs as this will increase blood flow to the heart and brain.
0^ If shock is not present at the onset it is important to keep it in mind because the woman's status may
worsen rapidly. Keep an IV line patent so that fluids could be given to woman fast if shock develops.
Keep the woman nil per oral (NPO)lnil by mouth
Treatment of APH involves cesarean section, which requires anesthesia. Having a full stomach
increases the risk of complications from anesthesia. Keeping the woman from taking anything orally
helps decrease this risk.
❖ Arrange for blood donor
If bleeding is significant, even if shock is not present, the woman may need a blood transfusion. Identify
a donor so that blood is available for her and that critical life saving care could be delivered in a timely
manner when she reaches FRU
❖ Do not do a per vaginal examination
Since placenta previa may be the cause of the bleeding, if placental location is not known, a pelvic
examination must not be performed, since this can lead to dangerous amount of bleeding.
❖ Administer antibiotics for rupture of uterus (ampicillin, gentamycin and metrogyl)
A ruptured uterus increases the risk of intra- abdominal infection. Give the initial dose of antibiotics as
it can help decrease this risk and/or begins treating the infection if already present. Three antibiotics
(gentamycin/ampicillin/metrogyl) are used because they cover the organisms most likely to be
involved in infection. Other antibiotics should not be used unless there is an allergy, as they may not
be as effective.
❖ Do not give inj oxytocin
Giving oxytocin contracts the uterine muscles and can make the bleeding worse.
Referralofwoman to FRU urgently
❖ Refer depending on the status of the woman urgently to the FRU. However if delivery is likely to occur,
it is important to conduct the delivery, continue the initial management, resuscitate the baby if needed
and then rapidly transport the baby and woman to a higher centre.
❖ The woman would require support through IV fluid administration and oxygen administration. The
baby might require to be resuscitated based on the status. It is important that the all equipment are
ready and at hand for such an emergency.
Skilled birth attendance care during labour, delivery and postnatal periods at 24/7 Primary Health Centres
Skilled birth attendance care during labour, delivery and postnatal periods at 24/7 Primary Health Centres
5D.3 Requirement for Initial Management for APH before Referral
Equipments andsupplies
In addition to the equipment and drugs listed in the general skill set section, in order to be able to perform
the specific set of skills needed to manage this complication ensure that the following drugs and equipment
are available and functional:
❖ Cap or inj Ampicillin 1 gm orally or IV
❖ Inj Gentamicin 80 mg IM of IV
❖ Tab or inj Metronidazole 400 mg orally or 500 mg IV
Clinicalskills
In addition to the skills listed in the general skill set section, the following skills are needed to manage
this complication:
❖ Assessment of BLOOD LOSS PER VAGINA (See Page number 115)
❖ Management of SHOCK (See page number 97)
5D.4 Key mentoring messages - Do's and Don'ts
DO always assess for signs ofshock and continuously be on the alert in a woman that is
bleeding. Hemorrhagic shock is life threatening and needs immediate treatment with
fluid replacement.
DO keep the woman nil per orally. Treatment of antepartum hemorrhage involves
cesarean section, which requires anesthesia. Having a full stomach increases the risk of
complications from anesthesia. Keeping the woman from taking anything orally helps
decrease this risk.
Do's
DO insert a Foley's catheter and IV access. A Foley's catheter helps you keep track of
urine output, which tells you if you are adequately replacing the blood loss. IV access is
needed to help provide volume replacement (fluids, blood) and treat shock.
•
—
___
— ......... ....,... ......... . ..... .........
DO identify and arrange for a blood donor. Identifying a donor ensures that blood
is available for the woman and that critical life saving care could be delivered in a
timely manner.
DO use a large gauge IV (16-18) since this lets fluid to go faster. This is important when
you need to replace blood loss quickly with large amounts of fluid in a short period of
time.
DO give the first dose of antibiotics in the case of ruptured uterus. This helps
prevent infection.
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DO give the first dose of corticosteroid if the gestational age is between 24-34 weeks.
This decreases neonatal morbidity and mortality.
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DO accompany the woman during referral. Changes in the status of the maternal
and fetal condition can happen quickly. Accompanying the woman ensures that
appropriate monitoring and care are also being delivered during transport.
DO NOT perform a pelvic examination on a pregnant woman over 20 weeks gestation
who presents with vaginal bleeding or a history of bleeding. If there is a placenta
previa, PV examination can cause very dangerous amount of bleeding that could result
in death.
DO NOT give uterotonics to a woman with antepartum hemorrhage. This can increase
Don'ts the bleeding.
DO NOT refer without making the woman stable first. In a bleeding woman, with or
without shock, IV access must be inserted, fluids must be given through IV access
and a Foley's catheter must be inserted. This is because bleeding can quickly become
dangerous and could lead to death if not initially treated.
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Skilled birth attendance care during labour, delivery and postnatal periods at 24/7 Primary Health Centres
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Infection or Sepsis in Pregnancy, Labour and/or
Postnatal Period
Section 5E
(See Complication Case Sheet D)
5E.1 Introduction
Infections are also a significant cause of maternal morbidity and mortality. Nearly 15% of maternal deaths in
India are due to infections that are otherwise preventable. Infections can occur anytime during pregnancy,
labour, delivery and postnatal period. The most common causes of infection with fever are: pyelonephritis
(kidney infection), amnionitis (infection of the uterus in pregnancy due to rupture of membranes),
endometritis/puerperal sepsis (infection of the uterus in the postnatal period), mastitis (breast infection),
breast abscess and wound infection/abscess (could be abdominal or perineal). Mild infections if untreated
can lead to severe infection or septic shock which could be fatal. Infections in pregnancy also increase the
risk of preterm birth; an intrauterine infection then it also increases the risk of neonatal sepsis.
5E.2:
Diagnosis and Initial Management of Sepsis
Identification ofsepsis
❖
If you do suspect septic shock, it is important to manage it appropriately before assessing for and
managing the specific cause of infection. All of these infections require treatment with antibiotics.
♦♦♦
Specific criteria are used to identify what is the cause for sepsis. Details of which are given in Table 5.3.
Table 5.3: Criteria for diognosis of infection
Signs/Symtoms
Infection
1. Septic shock
<♦
Systolic BP more than 90 mmHg
❖
Pulse more than 110/min
❖
Skin is cold and clammy
<* Woman appears anxious or confused or unconscious
2. Amnionitis
3. Endometritis / Puerperal sepsis
♦>
Fever may or may not be present
<♦
Fever (temperature more than or equal 38°C)
*>
Rupture of membranes
♦**
Abdominal pain
❖
Foul smelling or purulent discharge per vagina (may or may
not be present)
<♦
Fever (temperature more than or equal 38°C)
❖ Abdominal pain
*> Tender uterus
<•
Foul smelling or purulent lochia
Increased vaginal bleeding (may or may not be present)
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❖ Burning sensation while passing urine
4. Pyelonephritis
♦** Flank pain
<♦ Fever (temperature more than or equal 38°C) and chills
5. Mastitis
f.
Red and tender breast
<* Fever (temperature more than or equal 38°C)
6. Breast abscess
❖ Tender, discreet fluctuant mass in the breast
❖ Fever (temperature more than or equal 38°C) and chills
<♦ Pain in the breast
If any of the signs given are observed or reported by the woman, start initial
management and refer the woman to the nearest FRU or higher centre.
Initialmanagement ofsepsis
❖ Assess if shock is present or not - if present, provide fluids and antibiotics
Inj Ampicillin 2 gm IV
Inj Metronidazole 500 mg IV
Inj Gentamicin 80 mg IM or IV
❖ Whenever there is a serious infection it can spread from the original source to the blood leading to
sepsis. Sepsis can lead to septic shock. If shock is suspected, start IV line, replace fluids immediately
and give antibiotics. The three antibiotics are used because they cover the organisms most likely to be
involved in infection and septic shock. Other antibiotics should not be used unless there is an allergy,
as they may not be as effective
Pyelonephritis: Administer inj ampicillin 2 g IV and inj gentamycin 80 mg IM or IV: These are the
two drugs of choice for treating kidney infections. The reason they are not given orally is that the IV
route acts faster and these women are usually quite sick.
*
Amnionitis, endometritis /puerperal sepsis: Provide inj ampicillin 1 gm orally or IV, tab or inj
metronidazole 400 mg orally or 500 mg IV and inj gentamycin 80 mg IM or IV.
Mastitis and breast abscess: Provide cap cioxacillin 500 mg orally or cap ampicillin 500 mg orally or
tab erythromycin 250 mg orally Only one of these antibiotics are given - choose based on availability
as all of them cover the organisms most likely to be causing the infection. Usually cioxacillin is first
choice since there is less resistance to it, giving it has before a greater chance of being effective.
Wound infection: Provide cap ampicillin 500 mg orally and tab metronidazole 400 mg orally.
<♦ Provide tab paracetamol 500mg orally unless in shock. Paracetamol is a medication that helps to treat
fever (decreases the temperature) and pain.
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5E.3 Requirement for Initial Management for Sepsis
Equipments andsupplies
In addition to the equipment and drugs listed in the general skill set section, in order to be able to perform
the specific set of skills needed to manage this complication ensure that the following drugs and equipment
are available and functional:
❖ Normal saline IV fluid
❖ Ringer lactate IV fluid
❖ Cap or inj Ampicillin 1 gm orally or IV
❖ Inj Gentamicin 80 mg IM of IV
❖ Tab or inj Metronidazole 400 mg orally or 500 mg IV
❖ Cap Cioxacillin 500 mg orally
❖ Cap Erythromicin 250 mg orally
❖ Tab Paracetamol 500 mg orally
Clinicalskills
❖ Performing ABDOMINAL EXAMINATION (See Chapter 2, page 10)
❖ Performing PERINEAL EXAMINATION (See Chapter 3, page 43)
Performing a BREAST EXAMNATION (See Key for Case Study 5.3, page 105)
❖ Monitor and interpret VITAL SIGNS INCLUDING FETAL HEART RATE (See Chapter 2 page 19)
❖ Insert IV LINE, ADMINISTER AND CALCULATE FLUID RATES OR ADMINSTER IV INJECTIONS (See Section
5G.3, page 117)
❖ Insert a FOLEY'S CATHETER (See Section 5G.3, page 117)
♦> Administer OXYGEN (see Chapter 3, page....)
5E.4 Mentoring Skills
Sample ofcase study for use in mentoring
Case Study 5.3-Sepsis
Part A
Mrs. Geetha is a 22-year-old para 1 has come to the health centre complaining that she feels hot and
unwell. She reports that she gave birth vaginally to a full-term newborn 3 days ago at the health centre.
The newborn weighed 2.8 kg. She had a perineal laceration that required suturing. She was counseled
about danger signs before leaving the health centre, including the need to seek care early if any danger
signs occur.
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Chapter 5
1. Before you assess Mrs. Geetha, what are the possible common illnesses that could be causing her fever
today?
2. What will you include in your initial assessment ofMrs. Geetha, and why? This refers to both history and
physical examination.
3. What screening procedures/laboratory tests will you include (if available) in your assessment of
Mrs. Geetha and why?
PartB
You have completed your assessment of Mrs. Geetha and your main findings include the following:
History: Mrs. Geetha does not have abdominal pain, frequent or painful urination, abdominal tenderness,
foul-smelling lochia, breast swelling or redness, vomiting or diarrhea or loss of consciousness. Physical
Examination: Mrs. Geetha's temperature is 38°C, her pulse rate is 88 beats per minute, her blood pressure
is 120/80 mmHg and her respiration rate is 20 breaths per minute. There is no abdominal tenderness. Her
lochia is of normal colour and amount, and without bad smell. Her breasts are normal with no swelling or
redness. Her perineal wound is tender with redness and swelling present extending beyond the edge of
the incision. There is no discharge or pus present.
4. Based on these findings, what is Mrs. Geetha's diagnosis (problem/need), and why?
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Skilled birth attendance care during labour, delivery and postnatal periods at 24/7 Primary Health Centres
5. Based on your diagnosis (problem/need identification), what is your plan of care for Mrs. Geetha,
and why?
Key for Case Study 5.3 - Sepsis
Part A
Mrs. Geetha is a 22-year-old para 1 who has come to the health centre complaining that she feel shot
and unwell. Mrs. Geetha reports that she gave birth vaginally to a full-term newborn 3 days ago at the
health centre.The newborn weighed 2.8 kg and Mrs. Geetha suffered a perineal laceration that required
suturing. She was counseled about danger signs before leaving the health centre, including the need to
seek care early if any danger signs occur.
7. Before you assess Mrs. Geetha, what are the possible common illnesses that could be causing her
fever today?
Answer: All of the following points need to be mentioned and discussed. You do not want to give away
the answers but probe to see if the participants can provide them. For example if they do not
mention one ask "Are there any other causes of fever you can think of, why or why not?"-This
encourages them to actually think about the possible illnesses that could be causing the fever.
Explain that it is important to think about what the common causes are because this helps
direct you on what questions to ask on history and what to look at on physical exam.
All of the following are common causes of fever in the postnatal woman:
*:* Uterine infection (also called endometritis or puerperal sepsis)
❖ Wound infection - this could be either an infection of a perineal wound or a cesarean section wound
*:* Kidney infection (pyelonephritis)
*♦*
Breast engorgement
*:* Breast infection (this could be either a mastitis or a breast abscess)
❖ Viral infection causing diarrhea or vomiting
2. What will you include in your initial assessment of Mrs. Geetha, and why? This refers to both history
and physical examination.?
Answer: The following should be mentioned. In discussion explain why. If they do not mention all steps
probe by asking, "Is there anything else you would want to do, why or why not?
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❖ Greet Mrs. Geetha respectfully and with kindness. This helps build rapport with the patient.
❖ Tell her what is going to be done and listen carefully to her. Answer her questions in a calm and
reassuring manner.This helps build rapport with the patient.
A rapid initial assessment should be done to determine the degree of illness: her temperature, pulse, |
blood pressure and respirations should be noted. This is important to do as it quickly lets you know
how sick Mrs. Geetha is and if she has any signs of septic shock.
Ask while taking history specifically about the presence of other signs or symptoms, such as:
Abdominal pain or tenderness (this is a sign of uterine infection/endometritis/puerperal sepsis),
Bleeding, foul-smelling lochia (this also is a sign of uterine infection/endometritis /
*
puerperal sepsis),
Frequent or painful urination and flank pain (this is a sign of a kidney infection/pyelonephritis),
Swollen or red breasts (this could be a sign of breast engorgement or breast infection/
mastitis/abscess),
Any vomiting or diarrhea (this is a sign of a viral infection), and
*
*:*
Any loss of consciousness (this can indicate sepsis).
In addition to the initial rapid assessment on physical examination you want to perform the following:
Examine the breasts for signs-of swelling, pain and tenderness (these are a sign of engorgement)^
.^■0-
for any redness and swelling (this is a sign of an breast infection, mastitis), cracked nipples, and
for the presence of a lump or mass (this indicates a breast abscess)
Examine the perineal wound for any pain, tenderness, redness, discharge, swelling, abscess
formation (these are signs of a wound infection or abscess),
Examine the abdomen to see if there is any uterine tenderness (this is a sign of uterine
infection), and
Check the lochia to see if there is any purulent foul smelling lochia (this is also a sign of uterine
<*
infection).
3. What screening procedures/laboratory tests will you include (if available) in your assessment of
Mrs. Geetha and why?
Answer: None at this stage - she is stable.
PartB
You have completed your assessment of Mrs. Geetha and your main findings include the following:
History: Mrs. Geetha denies abdominal pain, frequent or painful urination, abdominal tenderness,
foul-smelling lochia, breast swelling or redness, vomiting or diarrhea or loss of consciousness. Physical
examination reveals: Mrs. Geetha's temperature is 38°C, her pulse rate is 88 beats per minute, her blood
pressure is 120/80 mmHg andher respiration rate is 20 breaths per minute. There is no abdominal
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Skilled birth attendance care during labour, delivery and postnatal periods at 24/7 Primary Health Centres
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tenderness. Her lochia is of normal colour and amount, and without offensive odor. Her breasts are
normal with no swelling or redness. Her perineal wound is tender with redness and swelling present
extending beyond the edge of the incision. There is no discharge or pus present.
4. Based on these findings, what is Mrs. Geetha's diagnosis (problem/need), and why?
Answer: Mrs. Geetha's symptoms and signs (e.g., wound tenderness, redness, fever) are consistent with
the diagnosis of perineal wound infection.
5. Based on your diagnosis (problem/need identification), what is your plan of care for Mrs. Geetha, |
and why?
Answer:
The following should be mentioned. In discussion explain why. If they do not mention all |
steps probe by asking, "Is there anything else you would want to do, why or why not?
❖
Explain the steps taken to manage the complication to Mrs. Geetha. Encourage her to express her [
concerns, listen carefully, provide emotional support and reassurance.
<♦
Perform one of two options: provide the first dose of antibiotic and refer to an FRU or if your MO is [
comfortable with managing as an outpatient you can prescribe a five day course of antibiotics and \
have her return for follow up.
Option one: Referral
<*
Provide the following antibiotics Cap Ampicillin 1 gm,Tab Metronidazole 400 mg and Inj Gentamicin |
80 mg IM stat. This will start to treat the infection immediately.
Provide analgesia to help with the pain and the fever. Tab Paracetamol 500 mg to take as 3-5 times |
per day as needed could be given.
❖
Make sure there is a good referral note including reason for referral, and medications given. This j
!
provides very helpful information for the people who will see Mrs Geetha at the higher centre.
Option two: Outpatient management and follow up
Get a prescription for Antiobiotics.This should consist of cap ampicillin 500 mg orally four times a day for I
5 days and tab metronidazole 400 mg orally three times a day for five days.
❖
See that analgesia is given to help with the pain and the fever. Tab paracetamol 500 mg to take |
3-5 times per day as needed could be given
<♦ Counsel about the need for good hygiene, to change her perineal pad/cloth at least three times a
day and to wear clean clothes. This will help keep the area clean.
<♦
Inform her to return the next day for follow up and to have the perineal dressing changed. This will
let you reassess Mrs. Geetha's wound to make sure it is getting better and not worse.
I *:*
Follow up on a daily basis until the wound has healed satisfactorily. This is necessary to make sure [
that Mrs Geetha is improving and not getting worse. If she does not improve then she would require j
referral for further management.
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Key points to review at the end of case study 5.3
Uterine infection, breast engorgement and infection, wound infection and kidney
infection are all common causes of fever in a postnatal mother. Anytime a postnatal
mother presents with a fever you should be thinking about these possible causes.
A careful history and physical examination focusing on these common causes will
help provide the correct diagnosis.
If the woman is managed as an outpatient, whatever the diagnosis is for the cause of
the fever, follow up is always needed to make sure that she is getting better.
If the woman is referred a good referral note should always be done and sent with her.
5D.4 Key Messages - Do's and Don'ts
DO always assess for signs of septic shock and continuously be on the alert for it
in’a woman that has a fever and sepsis. Septic shock is life threatening and needs
immediate treatment with IV fluids and antibiotics.
_____
DO provide the first dose of antibiotic prior to referral. Giving this first dose starts
treating the infection immediately and avoids delay in care.
Do's
DO determine the cause of the fever and use the correct antibiotic. Using the wrong
antibiotic can result in ineffective treatment and can lead to worsening infection.
DO encourage woman to practice good hygiene by having a bath daily, washing the
perineal area whenever she goes to the toilet and changing clothes.
DO practice infection control steps when performing any procedure on the woman.
DO NOT refer without initial treatment. Giving the first dose of antibiotics starts
treating the infection immediately and could be life saving.
DO NOT forget to determine the cause of the fever. Different causes need different
Don'ts types of antibiotics.
DO NOT give antibiotics that are not listed on the case sheets, unless there is an allergy.
These drugs may not be as effective at treating the infection.
SEI
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Section 5F Preterm Labour/ Preterm or Prelabour Rupture
of Membranes
See Complications Case Sheet
5F.1
Introduction
Pre-term labour is defined as the onset of labour prior to the completion of 37 weeks of gestation.
Preterm/premature pre labour rupture of membranes is the rupture of membranes (bag of water) before
37 weeks gestation and before labour begins. Premature prelabour rupture of membranes is the most
common cause of preterm labour. Preterm labour is important because infants born before 37 weeks are
at much greater risk of complications, such as infections, breathing problems, and even death.
5F.2 Diagnosis and Initial Management of Preterm Labour with or without
Preterm Rupture of Membranes
Identification ofpreterm labour orprematurepre labour rupture ofmembranes
Recognizing preterm labour and rupture of membranes is important as giving the woman antibiotics
and corticosteroids greatly improve outcomes in preterm newborns. The corticosteroids are safe to be
used for the woman and fetus and should always be given before referral.
❖ Thus early identification of either complication is important for prompt action to be taken. Some typical
signs of the two complications are given below
Table 5.4: Typical signs of preterm labour and PROM
Preterm labour
j Premature rupture of membranes (PROM)
❖ Gestational age between 24 and 37 weeks
❖ Gestational age between 24 and 37 weeks
❖ Active labour
❖ Rupture of membranes
❖ Temperature more than 38°C (may or may not be
present)
❖ Not in active labour
❖ Rupture of membranes (may or may not be present)
❖ Temperature more than or equal 38°C
(may or may not be present)
Initialmanagement
❖
If a woman presents with any of the two conditions it is best to refer her urgently to a higher centre unless
delivery is imminent. Before referral it is important to stabilise the woman.
❖ G/ve ampicillin ifpreterm labour with or without rupture of membranes and no fever
Premature babies are more at risk for getting infections. This antibiotic is given to prevent possible
infection transmission to the baby, during passage through the birth canal.
This antibiotic is used because it covers the organisms most likely to be causing the infection.
4*
Other antibiotics should not be used unless there is an allergy, as they may not be as effective.
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❖ G/Ve ampicillin, gentamicin and metronidazole ifpreterm labour (regardless of membrane status) with
fever or premature preterm rupture of membranes with fever with or without labour
-$•
In this situation the woman already has an infection, since she has a fever. We are giving these
antibiotics to treat the infection. These three antibiotics are used because they cover the organisms
most likely to be causing the infection.
❖ Other antibiotics should not be used unless there is an allergy, as they may not be as effective.
❖ Give ampicillin and erythromycin if rupture of membranes and no labour
In this case the woman has ruptured her membranes but is not in labour and has no fever. We are
giving the antibiotic to prevent infection and try to delay the start of labour until she can reach a
higher centre that has the needed facilities for the preterm baby. This is different than the other
cases where the woman is already in labour or has an infection/fever.
❖ Give corticosteroids ifgestationalage between 24 and34 weeksgestationalage
<
Babies born early do not have fully developed organs - especially their lungs. Corticosteroids help
reduce neonatal complications due to respiratory issues, as well as others including death. They
cause no harm to either the woman or fetus so should always be given. They are not given above
34 weeks gestation because studies show the benefits are only between 24-34 weeks gestation.
Referralto FRU
♦♦♦ Unless delivery is imminent all women with preterm labour and rupture of membranes should be referred
to a higher centre. The reason for referral is that the preterm newborn will require extra special care.
❖ If the baby is born at the PHC, breastfeeding should be initiated and the baby kept warm and close to the
mother (skin to skin contact) before and during transport.
❖ Criteria for correctly diagnosing preterm labour and preterm pre labour rupture of membranes are
included in complication case sheet E.
5F.3 Requirements for Initial Management of Preterm Labour with or without
Rupture of Membranes
Equipments and supplies
In addition to the equipment and drugs listed in the general skill set section, in order to be able to perform
the specific set of skills needed to manage this complication ensure that the following drugs and equipment
are available and functional:
❖ Cap or Inj Ampicillin 1 gm orally or IV
♦t*
Inj Gentamicin 80 mg IM of IV
❖ Tab or inj Metronidazole 400 mg orally or 500 mg IV
❖ Tab Erythromycin 250 mg orally
❖ Corticosteroids such as inj dexamethasone or inj betamethasone
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Clinical skills
In addition to the skills listed in the general skill set section, the following skills are needed to manage this
complication:
1. Estimate EDD (See Chapter 2, page 26)
2. Administer corticosteroids for gestational ages between 24-34 weeks (Refer Case sheet E)
5F.4 Mentoring Skills
Sample example formentoring using the complication case sheetE
❖ Review some case sheets that have been completed in the respective PHC before the planned
mentoring visit.
❖ Identify the strengths, gaps in documentation and make a note of it.
❖ Show some sample case sheets to the staff nurse on the day selected. Ask them "give the good points
and the gaps you can identify in the case sheet".
❖ Affirm them for the contribution.
❖ Highlight the strengths, gaps and then again the strengths of the documentation with specific
emphasis of complication case sheet E.
❖ Reinforce the importance ofearly identification, initial management and referral of the woman promptly.
❖ Check if they have any doubts.
*:* Thank them for their participation and cooperation.
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5F.5 Key Messages - Do's and Don'ts
DO always calculate gestational age for women who present in labour or with rupture
of membranes. Identifying preterm baby allows you to refer to higher facilities where
special newborn care could be provided, if delivery is not imminent.
DO always check to see if the woman has increased body temperature with rupture of
membranes. A woman with a fever already has an infection and needs different types of
antibiotics than one who is just in preterm labour.
Do's
DO provide the first dose of antibiotic prior to referral. Giving this first dose starts
preventing and /or treating the infection immediately and avoids delay in care.
DO give corticosteroids to all women who present between 24-34 weeks gestation with
preterm labour or preterm prelabour rupture of membranes.
DO refer to a higher centre that has the ability to care for premature infants. Being able
to appropriately care for a preterm infant increase its survival.
Don'ts
DO NOT forget to give corticosteroids to all women who present between 24-34 weeks
gestation with preterm labour or preterm prelabour rupture of membranes. They cause
no harm and significantly decrease neonatal morbidity and mortality.
DO NOT give antibiotics that are not listed on the case sheets, unless there is an allergy.
These drugs may nol be as effective at treating the infection.
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Section 5G Postpartum Hemorrhage
(See Complication Case sheet F)
5G.1 Introduction
Worldwide, postnatal hemorrhage is the leading cause of maternal deaths. It is also the leading cause of
maternal deaths in India and Northern Karnataka. It is defined as the loss of 500 ml or more of blood and
can occur early after delivery (the first 24 hours) or later (after 24 hours to 6 weeks post delivery).The most
common causes are uterine atony (flabby, boggy uterus that does not contract), cervical/ perineal tears
and retained placenta (complete or partial). It can occur as large and fast (torrential) sudden bleeding or
continuous slow bleeding over several hours.
The importance of the amount of blood loss is that it varies with the woman's hemoglobin level. Women
who are not anemic can tolerate blood loss which otherwise may lead to death in anemic women. However
even non-anemic women can also have severe blood loss that could be fatal.
5G.2 Diagnosis and Initial Management for PPH
How to make a diagnosis ofPPH
<♦ Sudden bleeding or continuous slow bleeding in any woman is an emergency. Early and quick
management is needed.
❖ Whenever PPH is suspected, it is important to assess for shock as well.
❖ Criteria for correctly diagnosing causes of PPH and shock are included in complication case sheet F.
These are listed in Table 5.5.
Table 5.5: Causes and diagnosis of PPH
Criteria for diagnosis
Cause
❖ Increased bleeding
1.
2.
3.
❖ Placenta expelled
❖ Soft and flabby uterus
Atonic uterus
❖
❖
❖
❖
Perineal / Cervical tears
Retained placenta (within first 24 hours after
delivery, could be complete or partial).This
could be a torn membrane with blood vessels.
4.
Delayed
PPH
(due
to
fragments)
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retained
placental
Increased bleeding
Placenta expelled
Uterus well contracted
Presence of tears seen
<* Increased bleeding
❖ Placenta not delivered either completely or
partially
Uterus may or may not be contracted
❖ Bleeding 24 hours after delivery not due to
any other cause
Start initialmanagement forPPH
❖ Assess if shock is present or not - ifpresent give fluids
❖ Do arrange for a blood donor
❖ Administer uterotonics for uterine atony: Giving uterotonics helps the uterus contract, which stops the
bleeding. Oxytocin is the first choice of treatment, but any of the other three drugs could be used if
oxytocin is not available.
Inj Oxytocin 20 IU in IV infusion in 1L of Ringer lactate or
Inj Methergine / Ergotamine 0.2 mg IM per dose (up to 5 doses) or
Inj Prostaglandin/ Carboprost 0.25 mg IM per dose (up to 8 doses) or
-0- Tab Misoprostol 800 mcg orally or rectally
❖ Massage the uterus:Massaging the uterus expels clots and helps it to contract to stop bleeding.
❖
Insert targe gauge IV (16-18) and insert Fo/ey's catheter: AW bleeding women need an IV started
and IV access.
Start IV with a large gauge IV (16-18) since this lets fluid run in faster.This is important when blood
loss must be replaced quickly.
Inserting a Foley has two benefits: it helps to monitor fluid status and keeps the bladder empty.
This could help uterus to contract.
❖ Remove theplacenta manually (with hand) andgiveprophylactic antibiotics: Inj ampicillin 7 gm /Vor
orally andinjmetronidazole500mg IVor400mg orally andinjgentamycin 80 mg IVorIM
When bleeding is due to retained placenta knowing how to manually separate it from the uterus
is a life saving procedure.
Since the hand has to be put into the woman's uterus to do this, a dose of antibiotics is given to
help prevent infection.
❖ Do bimanual compression of the uterus: When bleeding from the uterus has not responded to
treatment, compressing the uterus between two hands could directly apply pressure to it and decrease
the blood loss.
❖ Repair of vagina! tears andpack vagina with anti-septic soaked gauze if unable to repair: Actively
bleeding tears can cause lot of blood loss. It is important to identify this early and repair it early to stop
the bleeding. Suture, if easily accessible (first and second degree tears).
If the tear cannot be made out or reached easily (or third and fourth degree tears): Pack the vagina
with sterile dressing soaked in antiseptic prior to referral. This could decrease blood loss during
transfer of the woman to the FRU.
4-
Give the following prophylactic antibiotic in case of fourth degree tear
+ Cap ampicillin 500 mg orally
+ Tab metronidazole 400 mg orally
4*
Call and check the FRU for surgical intervention, if necessary.
Arrange for transport
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Skilled birth attendance care during labour, delivery and postnatal periods at 24/7 Primary Health Centres
❖ Administer uterotonics for delayedpostnatal hemorrhage (either inj oxytocin 10 !U, iM or IV or tab
misoprosoi800mcg rectally or orally) and antibiotics iffoulsmelling discharge: Delayed PPH (more
than 24 hours after delivery) is usually due to retained placental fragments. These retained fragments
act as a source of infection in the uterus and lead to bleeding. Giving antibiotics treats the infection and
the uterotonic helps contract the uterus and decreases the bleeding.
-$■ Call and determine the nearest FRU for dilatation and curettage (D&C), if necessary.
< Arrange transport for transfer to FRU.
Give either inj oxytocin 10 IU IM or IV or Tab misoprostol 800 mcg rectally or orally.
<
If there is foul smelling discharge, give the following antibiotics
4- Cap or inj ampicillin 1 gm orally or IV and
4- Tab or inj metronidazole 400 mg orally or 500 mg IV and
4 Inj gentamycin 80 mg IM or IV
Referralto FRU
<♦ Once the woman is stabilised it is important to make every effort to transfer her along with a support
person to the nearest FRU.
❖ Any delay in this process could contribute to poor prognosis of either one or both, i.e. the woman and
the baby.
5G.3 Requirements for Initial Management for PPH
Equipments and supplies
In addition to the equipment and drugs listed in the general skill set section, in order to be able to perform
the specific set of skills needed to manage this complication ensure that the following drugs and equipment
are available and functional:
❖ Cap or inj ampicillin 1 gm orally or IV
❖ Inj gentamycin 80 mg IM of IV
❖ Tab or inj metronidazole 400 mg orally or 500 mg IV
❖ Inj lignocaine 0.5% (10ml)
❖ Inj Methergin / ergotamine 0.25mg IM
❖ Inj prostaglandin / carboprost 0.25mg IM
❖ Inj oxytocin 20 IU in IV infusion in 1L of ringer lactate
❖ Tab misoprostol 800 mcg orally or rectally
❖ Sutures and suture kit
Clinical skills
In addition to the skills listed in the general skill set section, the following skills are needed to manage this
complication:
❖ Assessment of BLOOD LOSS PER VAGINA
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❖ Starting an INTRAVENOUS LINE
❖ Giving INTRAVENOUS FLUIDS
❖ CATHETERISING urinary bladder
❖ How to do MANUAL REMOVAL OF PLACENTA
❖ How to perform BIMANUAL COMPRESSION
❖ How to REPAIR TEARS
❖ Howto PACK THE VAGINA (see session on labour and delivery, page no 46)
1. If the sphincter is not injured, and there is no third or fourth degree tear, proceed with repair.Change to
clean, high-level disinfected or sterile gloves (you do not want to use the same gloves as the ones you
had used for performing the rectal exam as they can lead to infection).
2. Repair first and second degree tears
❖ Call for help (ask the ASHA worker if available) if a perineal tear is suspected.
❖ Explain what will be done to the woman, reassure her that analgesics/local anesthetic will be given
and encourage her to cooperate.
❖ Ask an assistant to check the uterus and ensure that it is contracted.
❖ Change gloves.
❖ Apply antiseptic solution to the area around the tear.
<♦ Administer local anesthetic beneath the vaginal mucosa, beneath the skin of the perineum and
deeply into the perineal muscle.
Load 10 ml 0.5% lignocaine solution in a syringe.
<
Use a small gauge needle to infiltrate as this is less painful for the woman.
<
Insert the needle carefully at a 15-30 degree angle after explaining to the woman what to expect.
-0- Aspirate (pull back on the plunger) to be sure that no vessel has been penetrated. If blood is
returned in the syringe with aspiration, remove the needle. Recheck the position carefully and
try again. Never inject if blood is aspirated. The woman can suffer convulsions and death if IV
injection of lignocaine occurs.
< Administer the injection in all layers, wait for two minutes and then pinch the area gently with
forceps. If the woman feels the pinch, wait for two more minutes and then retest.
❖ Repair the vaginal mucosa using a continuous 2-0 suture
Start the repair about 1 cm above the apex (top) of the vaginal tear. This will ensure that any
vessels that may be bleeding from above the very top of the tear are included. Not doing so can
lead to ongoing bleeding.
< Continue the suture to the level of the vaginal opening; at the opening of the vagina, bring
together the cut edges of the vaginal opening; bring the needle under the vaginal opening and
out through the perineal tear and tie.
❖ Repair the perineal muscles using interrupted 2-0 suture (See Figure 3.11). If the tear is deep, place
a second layer of the same stitch to close the space.
❖ Repair the skin using interrupted (or subcuticular) 2-0 sutures starting at the vaginal opening. If the
tear was deep, perform a rectal examination. Make sure no stitches are in the rectum.
Skilled birth attendance care during labour, delivery and postnatal periods at 24/7 Primary Health Centres
Skilled birth attendance care during labour, delivery and postnatal periods at 24/7 Primary Health Centres
Anterior
retractor-
ft
f.
fjr
A.-.:-*,.:
............. ...... .....__________
Repairing the vaginal mucosa
Repairing the perineal muscles
Repairing the skin
Figure 3.11: How to repair perineum tears
3. Post procedure care for ALL TEARS
❖ Ask assistant to monitor pulse, during and after repair of the tears. Check whether the woman is
feeling comfortable or has any uneasy feeling.
❖ Administer intravenous fluid if there is excessive bleeding.
❖
Follow up closely for signs of wound infection,
❖ Advise / administer sitz bath or warm compresses to help bring down the pain (encourage the
woman to sit on a basin with warm water with antiseptic solution once or twice a day as is possible).
❖ Give stool softener by mouth for one week, if possible.
Initial management of THIRD AND FOURTH DEGREE TEARS
1. Do not attempt to repair a third or fourth degree tear at the PHC.
2. Keep articles ready:
❖ Assorted sterile speculum -Sims or Bi-valve, various sizes
❖
Sterile scissors
❖ Sterile sponge holding forceps
❖ Gauze packs - 10cm width rolls. If more than one roll is required ensure they are tied together
securely
❖
Normal saline
Sterile gloves
❖ Antiseptic like povidone iodine.
3. Wash hands, wear sterile gloves.
4. Ensure that the bladder is emptied by inserting a catheter.
5. Startan IV line for the woman.
6. Give an analgesic to reduce pain.
7. Pack the vagina with sterile dressing.
❖
Soak the gauze in antiseptic solution and squeeze to drain the excess antiseptic.
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❖ Expose the vagina using the Sims or Bivalve speculum under good light.
❖ Introduce one end of the gauze into the uppermost part of the vagina using the sponge holding
forceps.
❖ Pack the vagina with the gauze by folding with the sponge holding forceps.
❖ Ensure that the other end of the gauze is clearly visible after packing. Place a perineal pad and ask
the woman to place her legs together and lie in the left lateral position.
8. Note in the case sheet (use complication case sheet F) the time and date of insertion of the vaginal pack.
9. Give the following prophylactic antibiotic in case of third or fourth degree tear:
❖ Ampicillin 500 mg orally;
❖ Metronidazole 400 mg orally.
10. Call and inform the higher centre for surgical intervention, if necessary.
11. Arrange transport to a higher facility for repair.
Assessment of BLOOD LOSS PER VAGINA
1. Estimate amount of blood loss after the delivery. Any blood loss can affect the woman adversely during
labour or after birth up to six weeks after delivery.
2. Remember that very accurate assessment of vaginal bleeding may not be possible. The other indicators
of increased bleeding are:
❖ Continuous passage of clots per vaginum or passage of large clots.
4* Soakage of more than one pad (sanitary pad 6x10 inches in size, Vi inch thick) rn five minutes. ❖ Gushing of blood from the vagina.
3. Check the vital signs and be alert for shock
❖ If pulse rate is rapid and feels very weak it could indicate more blood loss.
❖ If the BP is below 90/60 mmHg.
4. When in doubt start treatment and reassess for shock (Shock in the woman is defined as a condition
with a systolic BP less than 90 mmHg and /or pulse of more than 110/minute and may be associated
with loss of consciousness, cold and clammy skin)
❖ Give IV fluids as detailed below.
❖ Slow the IV drip to 3 drops per minute if the systolic BP increases to more than or equal 100 mmHg
and pulse slows down to less thanlOO/min.
❖ Keep the woman warm, keep her feet elevated.
❖ Give oxygen.
❖ Keep the woman nil by mouth (This is necessary if she needs a surgery).
Starting AN INTRAVENOUS LINE
1. Keep articles and equipment required for the procedure
❖ Intravenous stand
❖ Intravenous drip set and intravenous fluid - Ringer Lactate/ Dextrose Normal Saline/Normal Saline
Skilled birth attendance care during labour, delivery and postnatal periods at 24/7 Primary Health Centres
Skilled birth attendance care during labour, delivery and postnatal periods at 24/7 Primary Health Centres
❖
IV cannula of 16/18 gauge
<♦ Clean gloves
❖
Spirit swab
❖ Tourniquet
❖
Leucoplast/adhesive plaster
❖ Splint with bandage.
2. Tell the woman and her support person what is about to be done.
3. Prepare the tubing by filling it with the IV fluid to be given and making sure there are no large air bubbles.
4. Position the woman's arm. The arm should be extended and supported. Apply the tourniquet or ask her
companion to hold the upper arm firmly. (Veins are easiest to see at the back of the hand or forearm).
Palpate the vein to be cannulated.
5. Wash hands with soap and water. Wear clean gloves on both hands.
6. Identify and clean the site with cotton and spirit. Allow to dry. Do not repalpate the vein
7. Remove the cannula from its packaging and remove the needle cover. Be careful not to touch the needle.
8. Stretch the skin distally and tell the woman to expect a sharp scratch. Insert the needle, bevel upwards
at about 30 degrees.
9. Advance the needle until a flashback of blood is seen in the hub at the back of the cannula. Once this is
seen, progress the entire cannula a further 2mm then fix the needle advancing the rest of the cannula
into the vein.
10. Release the tourniquet, apply pressure to the vein at the tip of the cannula and remove the needle fully.
11. Remove the cap from the needle and put this on the end of the cannula.
12. Carefully dispose of the needle into the sharps box.
13. Apply the plaster to the cannula to fix it in place.
14. Take a syringe (5cc) filled with saline and flush it through the cannula to checkfor patency. If there is any
resistance, if it causes any pain or if any localised tissue swelling is noticed immediately stop flushing,
remove the cannula and start again. If there is no
swelling or pain, connect the IV tubing with the
IV fluid.
15. Dispose of the cotton swabs in the waste bin,
needle in the needle destroyer and mutilated
syringe in the puncture-proof box.
16. Take off gloves and put them in 0.5% chlorine for
10 minutes for decontamination.
17. Wash hands with soap and water.
Figure 5.3: Starting an IV line
18. Record the proceedings in the complication case sheet F.
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Giving INTRAVENOUS FLUIDS
1. Insert an IV line using a 16-18 gauge cannula.
2. Attach a bottle of ringer lactate or normal saline or dextrose normal saline. Ensure that the infusion is
running well.
3. Infuse fluids rapidly if the woman is in shock (systolic BP less than 90 mmHg, and/or pulse more than
110/minute), or if the woman has heavy vaginal bleeding
❖ Infuse the first 1 litre (2 bottles) ini 5-20 minutes, i.e. as fast as possible.
❖ Infuse the next 1 litre in 30 minutes (at a rate 30 ml/minute). Repeat if necessary.
4. Monitor the BP and pulse every 15 minutes. Checkfor the presence of shortness of breath and/or puffiness.
5. If the systolic BP increases tolOOmmHg or more, and the pulse slows down to less thanlOO/ min,
❖ Slow down the IV infusion to 3ml/minute (i.e.1 litre in 6-8 hours).
❖ Reduce to O.Sml/minute if the woman has difficulty in breathing or puffiness.
6. Give fluids at a moderate rate in cases of obstructed labour.
❖ Infusel litre (2 bottles) of fluid in 2-3 hours.
7. Give fluids at a slow rate in cases of severe anaemia, severe pre-eclampsia and eclampsia.
❖ Infusel litre (2 bottles) of fluid in 6-8 hours.
How to CATHETERISE THE URINARY BLADDER
1. Keep all the articles ready
❖ Sterile/HLD gloves.
❖ Pre-sterile indwelling catheter (Foley) or disposable (sterile) plain catheter.
❖ Lignocaine jelly/ Lubricant Jelly
❖ 10 cc syringe and needle.
♦♦♦ Normal saline/ Sterile water for balloon inflation.
❖ Kidney tray.
❖ Sterile gauze/ cotton swabs, antiseptic solution: savlon/ povidone Iodine
❖ Urine collection bag with tubing.
❖ Leucoplast/adhesive plaster.
<♦ Torch light in case of power failure/ inadequate light
2. Explain to the woman (and her support person) what is going to be done. Respond to her questions
and concerns if any. Provide continual emotional support and reassurance.
3. Place a clean cloth under the woman's buttocks.
4. Wash hands thoroughly with soap and water, and dry them with a clean, dry cloth or air dry.
5. Wear new, sterile or HLD gloves on both hands.
6. Use one hand to gently separate the woman's labia
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7. Use the other hand to cleanse the labia and urethral opening with clean or sterile cotton or gauze and
antiseptic solution, wiping from front to back towards the anus.
8. Place a kidney tray between the woman's legs, close to the perineum. Place the open end of the catheter
in the kidney tray Ask the person assisting to squeeze a few drops of Lignocaine jelly/ Lubricant jelly
into the kidney tray. Lubricate upto 2 inches of the tip of the catheter by rolling it the jelly. Maintain
sterility of the tip of the catheter throughout.
9. Use one gloved hand to gently separate the labia from above.
10. Use the other hand to gently insert the tip of the catheter into the urethral opening upto 3 inches.
11. Gently give pressure over the pubis to empty the bladder completely.
12. Gently remove the plain catheter when the bladder is empty (when urine stops draining into the
kidney basin).
13. Attach the open end to tubing on a sterile urine bag and tubing, in the case of a self-retaining catheter,
14. Use a sterile syringe to inflate the balloon with 10cc of sterile water. Check if the woman has any pain or
discomfort. If so stop, and push catheter in slightly more inside. Again inflate the balloon.
15. Attach the catheter to the inside of the woman's thigh, using tape.
16. Secure the catheter bag to the side of the bed, below the level of the mother's bladder.
17. Measure and record urine output in all cases.
18. After the procedure
❖ Before taking off gloves, dispose of the waste materials in a leak- proof container or plastic bag.
❖ Destroy the needle and syringe with needle cutter, and dispose in puncture proof container.
❖ Take off gloves.
❖ Dispose the gloves, in a plastic bag or leak-proof, covered waste container.
❖ Wash hands thoroughly with soap and water, and dry them with a clean, dry cloth (or air dry).
❖ Document action taken in the case sheet
Removal of RETAINED PLACENTAL FRAGMENTS
1. Get help, if MO officer is available or another staff nurse.
2. Keep article ready (sterile gloves, towel, artery forceps, thumb forceps, sterile pads, speculum, ovum
forceps or wide currette)
3. Wash hands
4. With gloved fingers, insert the fingers gently per vagina, feel inside the uterus for placental fragments,
(manual exploration of the uterus is similar to the technique described for removal of the retained placenta)
5. Remove placental fragments by hand, ovum forceps or wide curette
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Chapter 5
Remember:
❖ Very adherent tissue may be placenta accreta. If an attempt is made to
remove these pieces of placenta from the uterus, may result in heavy
bleeding or uterine perforation which usually requires hysterectomy.
❖ If bleeding continues, assess clotting status using a bedside clotting test.
Failure of a clot to form after seven minutes or a soft clot that breaks down
easily suggests coagulopathy (bleeding problem).
❖ Refer the woman urgently to the nearest FRU or health centre.
Performing under professional supervision or with help MANUAL REMOVAL OF PLACENTA
1. Call for help. Do not attempt manual removal of placenta without supervision of medical officer.
2. Provide emotional support and encouragement.
3. Start IV infusion to stabilise the woman.
4. Review the indications.
5. Collect all the needed articles, equipment and medications.
6. Wash hands and wear protective equipment (sterile gloves, mask, goggles, apron and mask).
7. Give pethidine and diazepam IV slowly (do not mix in the same syringe) or use ketamine.
8. Catheterize the bladder or ensure that it is empty.
9. Give a single dose of prophylactic antibiotics (all three);
❖ Cap or inj ampicillin Igm IV or orally and
<♦ Tab or inj metronidazole SOOmg IV or 400 mg orally and
❖ Inj gentamycin 80mg IV or IM
10. Give inj oxytocin 20 units in 1L IV fluids (normal saline or ringer's lactate) at 60 drops per minute. Hold
the umbilical cord with a ctamp. Pull the cord gently until it is parallel to the floor
11. Start the actual procedure once professional help is available.
❖ Insert a hand into the uterine cavity if the cord has been detached previously. Explore the entire
cavity until a line of cleavage is identified between the placenta and the uterine wall.
❖ Hold the umbilical cord with one hand if the cord had not been detached. Insert the other hand
(dominant hand) into the vagina as given in the, Figure 5.4a
4+
Let go of the cord and move the hand up over the abdomen in order to support the fundus of
the uterus and to provide counter-traction during removal to prevent inversion of the uterus.
Move the fingers of the hand in the uterus laterally until the edge of the placenta is located.
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Skilled birth attendance care during labour, delivery and postnatal periods at 24/7 Primary Health Centres
I
❖ Detaching the placenta
❖
Support the fundus while detaching the placenta, from the implantation site by keeping the
fingers tightly together and using the edge of the hand to gradually make a space between
the placenta and the uterine wall. Proceed slowly all around the placental bed until the whole
placenta is detached from the uterine wall.
*
Use gentle lateral movement of the fingertips at the line of cleavage, remove placental
fragments if the placenta does not separate from the uterine surface.
< Hold the placenta and slowly withdraw the hand from the uterus, bringing the placenta with
it. With the other hand, continue to provide counter-traction to the fundus by pushing it in the
opposite direction of the hand that is being withdrawn.
Palpate the inside of the uterine cavity to ensure that all placental tissue has been removed.
■0- Continue inj oxytcoin 20 IU in 1L of ringer's lactate or normal saline or 5% dextrose salin at 30 drops
per min.
-0- Ask an assistant to massage the fundus of the uterus to encourage a tonic uterine contraction,
and to monitor BP/Pulse.
12. Examine the uterine surface of the placenta to ensure that it is complete.
13. If any placental lobe or tissue is missing, explore the uterine cavity to remove it.
14. After the procedure
Figure 5.4a: Apply traction to cord while inserting
other hand into vagina
Mentors' Manual Volume 2
Figure 5.4b: Apply fundal pressure while gently
separating the placenta
:
...............................................
■
-
If the placenta is retained due to
a constriction ring or if hours or
days have passed since delivery,
it may not be possible to get the
entire hand into the uterus. Call
the medical officer urgently to
Figure 5.4c: Give counter traction at the fundus while
gently removing hand with placenta. Apply fundal
pressure while gently separating the placenta.
extract the placenta in fragments
using two fingers, ovum forceps
or a wide curette.
❖ Observe the woman closely until the effect of IV sedation has worn off.
❖ Monitor vital signs (pulse, blood pressure, respiration) every 30 minutes for the next 6 hours or until
stable.
❖ Palpate the uterine fundus to ensure that the uterus remains contracted.
❖ Check for excessive lochia.
❖ Continue infusion of IV fluids.
❖ Blood transfusion may be required,make arrangement for a donor.
Performing BIMANUAL COMPRESSION
1. Wear sterile gloves, insert a hand into the vagina and remove any blood clots from the lower part of the
uterus or cervix; form a fist.
2. Place the fist into the anteriorfornix and apply
pressure against the anterior wall of the uterus.
3. Press deeply into the abdomen behind the uterus
with the other hand,applying pressure against the
posterior wall of the uterus.
4. Maintain compression during transport and until
bleeding is controlled and the uterus contracts.
Figure 5.5: Applying bimanual compression
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5G.4: Mentoring Skills
Case Study 5.4 -PPH
Part A
You have just delivered Mrs. Yasmin, a 30 year old gravida 4 para 4 at the PHC. She had a vaginal delivery
for a live born, 2.6 kg baby boy.
7. What will you do to actively manage the third stage of labour and decrease the risk of postnatal
hemorrhage in this woman?
PartB
2. Mrs. Yasmin delivers the placenta. After delivery of the placenta what do you want to check for and
why?
PartC
3. On examination the uterus is well contracted and there are no perineal tears. The placenta and
membranes are intact. One hour later she begins to have heavy PV bleeding. What would you like to do
on your initial assessment of Mrs. Yasmin and why?
PartD
You have completed your initial rapid assessment of Mrs. Yasmin and your findings include the following:
Her temperature is 36.8°C, her heart rate is 100 beats per minute, her blood pressure is 116/74 mmHg and
her respirations are 18 per minute. She is alert and oriented. Her uterus is soft and boggy. There are no
perineal, vaginal or cervical tears.
Mentors'Manual Volume 2
4. Based on these findings, what is Mrs. Yasmin's diagnosis and why?
5. Based on these findings do you think shock is present?
6. How will you manage her and why?
PartE -
-
You correctly diagnose uterine atony. You have performed uterine massage, removed all clots from the
uterus, administered oxytocin 10 Units IM x 1, started an IV with and inserted a Foley's catheter. She has IV
fluids of 1 litre of NS with 20 units of oxytocin running at 60 drops per minute. Her uterus is now firm and
well contracted. Repeat vital signs show a heart rate of 86/min, blood pressure of 108/72, temperature of
36.9°C and respiratory rate of 16/min. Her haemoglobin is 8 gm/dl.There is no further PV bleeding.
7. Based on these findings, what is your continuing plan of care for Mrs. Yasmin and why?
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Skilled birth attendance care during labour, delivery and postnatal periods at 24/7 Primary Health Centres
Key for case study 5.4 - PPH
Part A
You have just delivered Mrs. Yasmin, a 30 year old gravida 4, para 4, at the PHC. She had a vaginal delivery
for a live born, 2.6 kg baby boy.
7. What will you do to actively manage the third stage of labour and decrease the risk of postnatal
hemorrhage in this woman?
Answer: Perform active management of the third stage of labour, which involves the following
components. You do not want to give away the answers but probe to see if the participants
can provide them. For example if they do not mention giving uterotonics -ask"would you give
any medications, why or why not?" - this encourages them to actually think about the steps
that need to be taken.
❖ Administer a uterotonic drug (5-10 mg IV or IM of oxytocin or 600 micrograms rectally of
misoprostol, or 0.2 mg IM of ergometrine). Mention that oxytocin is the preferred drug but
that the others are also acceptable to use if oxytocin is not available.
❖ Clamp the cord.
.
❖ Give gentle, controlled cord traction with one hand on the fundus to prevent uterine
inversion.
<♦
Discuss that these three actions have been shown to decrease the risk of PPH and should be
performed on all women as routine care. This is especially important to do in the Northern
Karnataka context since PPH is the leading cause of maternal deaths.
J
PartB
2. Mrs. Yasmin, delivers the placenta. After delivery of the placenta what do you want to check for and
why?
Answer: The following should be mentioned. In discussion explain why. If they do not mention all
steps probe by asking, "Is there anything else you would want to do, why or why not?"
<♦ Check if the placenta and membranes are intact, because retained placental tissue/ |
fragments can lead to ongoing bleeding and be a cause of PPH.
<♦ Check if the uterus is firm and contracted since uterine atony is the most common cause of [
PPH (it is responsible for 80% of all PPH cases).
❖
Examine the perineum, vagina and cervix for tears. This is because tears are the most likely [
cause of PPH if the uterus is firm and well contracted and the placenta is complete.
❖
Estimate if the amount of blood loss at delivery is normal or abnormal. This helps to get a (
sense of what is a normal or too much bleeding after delivery.
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PartC
On examination the uterus is well contracted and there are no perineal tears. The placenta and
membranes are intact. One hour later she begins to have heavy PV bleeding.
3. What would you like to do on your initial assessment of Mrs. Yasmin and why?
Answer: All of the following points need to be mentioned and discussed. You want to reinforce that
there needs to be a sequential order to doing things and that in reality if two health care
providers are present at the same time many of these steps happen simultaneously. If they do
not mention all steps probe by asking, "Is there anything else you would want to do, why or
why not?"
❖ Call for help - this allows the nurse to have additional help to manage the woman. If help is
not available do not wait for help to come to assess the woman.
❖ Do an initial rapid assessment of Mrs. Yasmin to look for signs of shock and if she is in
need of emergency resuscitation. These signs include: pulse more than 110, systolic blood
pressure less than 90mm Hg, sweatiness, cold, clammy skin, rapid breathing, altered level of
consciousness, confusion.Temperature should also be checked to rule out infection.
❖ Check the uterus immediately to see if it is contracted. Explain that this is done because
80% of all PPH is due to uterine atony and even though it was firm before it may have
become atonic.
❖ Re examine the perineum, vagina and cervix carefully for tears. While this was done
previously - now that the bleeding has started again, this is done to make sure that you did
not miss anything on earlier examination.
PartD
You have completed your initial rapid assessment of Mrs. Yasmin and your findings include the following:
Her temperature is 36.8° C, her heart rate is 100 beats per minute, her blood pressure is 116/74 and her
respirations are 18 per minute. She is alert and oriented. Her uterus is soft and boggy. There are no
perineal, vaginal or cervical tears.
4. Based on these findings, what is Mrs. Yasmin's diagnosis and why?
5. Based on these findings do you think shock is present?
Answer: Uterine atony without signs of shock. Explain that the findings of a soft, boggy, uncontracted
uterus are consistent with the diagnosis of uterine atony. Review again the signs of shock (pulse
more than 110, systolic BP less than 90mmHg, sweatiness, cold, clammy skin, rapid breathing,
altered level of consciousness, confusion).
6. How will you manage her and why?
Answer: All of the following points need to be mentioned and discussed. You want to reinforce that
there needs to be a sequential order to doing things and that in reality if two health care
providers are present at the same time many of these steps happen simultaneously. You do
not want to give away the answers but probe to see if the participants can provide them. For
example if they do not mention starting an IV -ask "Would you start an IV, why or why not?" -
r 124 ]
Skilled birth attendance care during labour, delivery and postnatal periods at 24/7 Primary Health Centres
Skilled birth attendance care during labour, delivery and postnatal periods at 24/7 Primary Health Centres
this encourages them to actually think about the steps that need to be taken.
<♦ Call for help/assistance as many things need to be done simultaneously. Mrs. Yasmin should
not be left unattended nor should there be a delay caring for Mrs. Yasmin while help is on
its way or if help is unavailable.
❖
Begin uterine massage and continue until the uterus is firm. This helps the uterus contract.
Do a pelvic examination to remove any clot from the uterus. As long as there is clot in the
uterus the uterus will not be able to contract.
❖ Give an additional dose of Oxytocin 10 IU, IM x 1 immediately. If oxytocin is not available
then one of the following uterotonics could be given via an alternate route (800 micrograms
of misoprostol rectally, 0.2 mg IM of ergometrine) to help the uterus contract. Explain
that oxytocin is the preferred drug of choice, followed by misprostol, then ergometrine
(ergometrine has more adverse effects such as increasing the blood pressure). Use this point
to reinforce that the new case sheets will have information on dosages, repeat dosages and
8
contraindications.
❖
Start an IV with a large bore needle (16 or 18 guage) and run 20 IU, of injectable oxytocin in
1 litre of ringer lactate or normal saline at 60 drops per minute then follow with an additional
20 IU, of injectable oxytocin in 1 litre of IV fluids at 40 drops per minute.
❖ Give another dose of uterotonic if the woman continues to bleed and the uterus does
not contract after performing the above steps. Anyone of the following uterotonics
could be given via an alternate route (800 micrograms of misoprostol rectally, 0.2 mg IM
of ergometrine) to help the uterus contract. Use this point to reinforce that the new case
sheets will have information on dosages, repeat dosages and contraindications.
<* Start an IV and begin fluids of either NS or RL at 40-60 drops per minute. Explain that placing an
IV ensures that more fluid could be given if needed or additional medications if she continues
to bleed. Giving fluids immediately makes sure that the woman does not go
❖
Insert a Foley's catheter to help. Catheter help keep the uterus contracted by making
sure the bladder is empty. It is also is a useful way to measure urine output if the woman
continues to bleed.
❖ Continue to recheck her vital signs. This will let the nurse” know if the woman is remaining
stable or is beginning to deteriorate and show signs of shock.
❖
Do not do crossmatch of her for blood if she is not in shock.
❖
Do not draw blood for hemoglobin immediately if she does not continue to bleed and if she [
responds to initial management.
PartE
[
You correctly diagnose uterine atony. You have performed uterine massage, removed all clots from
the uterus, administered oxytocin 10 IU, IM x 1, started an IV with normal saline and inserted a Foley's |
catheter. She has IV fluids of 1 litre of NS with 20 IU of oxytocin running at 60 drops per minute. Her [
uterus is now firm and well contracted. Repeat vital signs show a heart rate of 86 per minute, blood |
pressure of 108/72mmHg, temperature of 36.9°C and respiratory rate of 16. Her hemoglobin is 8gm/ |
dl. There is no further PV bleeding.
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Chapter 5
7. Based on these findings, what is your continuing plan of care for Mrs. Yasmin and why?
<♦ Continue to monitor Mrs. Yasmin's vital signs and blood loss, every 15 minutes for 1 hour, then every
30 minutes for 2 hours, every hour for 3 hours and then every 4 hours for 24 hours. Check her uterus
to make sure that it remains firm and well contracted. Encourage her in addition to breastfeed her
newborn. She needs to have this additional close monitoring because you want to make sure she
does not start to bleed again. Breastfeeding releases oxytocin and this helps to keep the uterus
contracted to prevent bleeding.
❖ Check for anemia, 24 hours after the bleeding has stopped, by doing a hemoglobin or hematocrit.
❖ Give Mrs. Yasmin's IFA tablets once daily for 6-9 months if hemoglobin is below 11 gm/dl. This will
help increase her iron stores and increase her hemoglobin.
♦♦♦
DO NOT give blood transfusion if her vital signs are stable and there is no further bleeding.
<♦
Encourage the woman to express her concerns, listen carefully, and provide emotional support and
reassurance.
❖ Advise Mrs. Yasmin to remain at the health centre for an additional 24 hours, and before discharge
counsel about danger signs in the postnatal period (bleeding, abdominal pain, fever, headache,
blurred vision), compliance with iron/folic acid treatment and the inclusion in her diet of locally
available foods rich in iron; and to continue breast feeding her newborn.
<♦
Inform her that she and her baby should be seen by a healthcare provider approximately 5 to 6 days
after discharge.
-
-
-
..........
J
Key points to review at the end of the case study 5.4
❖ Perform AMTSL on all women after delivery of the baby.
<♦
Inspect the placenta and membranes, perineum, vagina and cervix and
uterine tone routinely after all deliveries to identify and/or prevent early PPH.
❖ Remember early PPH is defined as bleeding greater than 500 ml in the first
24 hours after delivery. Determine carefully if the bleeding is much heavier
than it should be (i.e. not a normal amount).
❖ Remember the most common cause of early PPH is uterine atony (80% of all
cases). Perineal, vaginal and cervical tears, followed by retained placenta or
placental fragments are the next most common causes.
Perform an initial rapid assessment to determine if the patient is in shock or
not and requires immediate resuscitation always
Never leave a bleeding woman alone. Women who have had an immediate
PPH need increased monitoring for the next 24 hours to make sure no
further bleeding occurs.
Skilled birth attendance care during labour, delivery and postnatal periods at 24/7 Primary Health Centres
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Skilled birth attendance care during labour, delivery and postnatal periods at 24/7 Primary Health Centres
.........
_ ____________ _
5G.5 Key Messages- Do's and Don'ts
DO always practice AMTSL. This prevents postnatal hemorrhage from uterine atony.
DO watch the woman, her bleeding and vital signs following delivery. Being able to
recognize postnatal hemorrhage early and act quickly is life saving.
DO be fast and treat early any woman who has sudden bleeding or continuous slow
bleeding after delivery.
DO always assess for signs of shock and continuously be on the alert for it in a woman
that is bleeding. Hemorrhagic shock is life threatening and needs immediate treatment
with volume replacement.
Do's
DO insert a Foley's catheter and IV access with a large bore needle. A Foley's catheter
helps keep track of urine output, which tells if blood loss has been replaced adequately.
IV access is needed to help provide volume replacement (fluids, blood) and treat shock.
A large bore needle is better since fluid / blood can be replaced rapidly if needed.
DO always take the time to determine the cause of the postnatal hemorrhage. This is
important since different causes have different treatments.
DO identify and arrange for a blood donor. Identifying a donor ensures that blood
is available for the woman and that critical life saving care could be delivered in a
timely manner.
DO know the doses, routes and contraindications of the utertonic medications. These
are life saving drugs and you should be familiar with them.
DO keep the emergency drug tray in the labour room. Having it in the same room ensures
you have immediate access to the needed drugs if hemorrhage occurs.
DO accompany the woman during referral. Changes in the status of the maternal
condition can happen quickly. Accompanying the woman ensures that appropriate
monitoring and care are also being delivered during transport.
DO NOT ignore sudden bleeding or continuous slow bleeding after delivery. Early and
fast management of postnatal hemorrhage is necessary in order to prevent it from
being fatal.
Don'ts
DO NOT ignore the woman or leave her unattended in first two hours of the postnatal
period. Close monitoring of the woman, her vital signs and bleeding will help to identify
hemorrhage and act quickly to prevent shock.
DO NOT refer a bleeding woman without initially stabilizing her first.
DO NOT keep the emergency drug tray far away from the labour room. Not having life
saving medication nearby during an emergency wastes precious time and could be fatal.
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Chapter 6
Preparation for Discharge
Reference: SBA guidelines 2010 Page 58,85
Learning Objectives
At the end of this chapter you will be able to
❖ Demonstrate the counselling skills required before discharge including danger signs for mother and
newborn, follow up and care, and FP advice
❖ Demonstrate documentation of discharge for woman and baby
❖ Demonstrate mentoring skills for discharge
-
6.1 Introduction
The first 48 hours is known to be the most crucial period for the development of complications both for
a woman and her baby. A woman who does not have any complications in the postnatal period could be
discharged in 48 hours. However it is important to assess for any danger signs, check whether the woman
is aware of her own care and the care of her baby and if she knows when she must come again for a follow
up visit.
Effective communication is a major component of providing health care and counselling. It is to be able to
listen, hear and respond to the patient's concerns, to make sure the patient feels respected and comfortable
discussing health and social problems, to empower the patient with information and skills to manage their
own health effectively. Good communication includes listening, being empathetic and non judgemental.
Listening means to pay close attention to someone; to hear with intention. Good listening involves listening
ACTIVELY. Listening is one of the key roles of a counsellor, a nurse and any health care provider. A good
listener doesn't interrupt, allows silences, does not speak until they have listened, let's the other person see
you are listening by nodding, maintaining eye contact and asking questions. Good listening skills include
good body language too.
6.2 Components of Preparation for Discharge
Assess for danger signs
Most of the common complications during the postnatal period could be picked up by careful and regular
monitoring of vital signs, and specific signs related to the obstetric period.
Check on knowledge of woman on care of herself at home
Counsel on postnatal care
I
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Skilled birth attendance care during labour, delivery and postnatai periods at 24/7 Primary Health Centres
Counsel on newborn care
6.3 Importance of Components for Discharge Preparation
Assess for danger signs
❖
It is essential that the woman is checked for the following in the first 48 hours every six hours (See
Section 4 of Normal Delivery Case sheet)
4
Bleeding PV, increased
4
Blurred vision / headache
4
Breathing difficulties
4
Convulsions
4 Fever
4- Pain: abdominal, perineal, breast
❖
<
Vomiting
4-
Swollen and red, tender breasts
In addition observation of the uterine tone, height, tenderness; tear condition; lochia characteristics.
Any abnormality of these observations could indicate a complication.
❖ The woman could be discharged if she does not present with any danger signs, is feeding her baby well
and is confident about the care or herself and the baby. Thus the staff nurse has an important role in
preparing the woman for discharge.
A woman who is healing well will have normal vital signs, uterus that is well
contracted, bleeding that is minimal, no problems in feeding her baby, and could
manage with the discomfort of a contracting uterus and pain related to episiotomy.
Check on knowledge and practice of woman on care of herself and the newborn
❖
Ask simple questions to the woman to help elicit how much she knows about the care of herself
Her diet
*
Hygiene
-0-
Danger signs
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Follow up visit
Specific to the care of baby (See Part C, Chapter 3 page number 47)
Traditional practices at home with regards to her and her newborns care
Counsel on various postnatal aspects of care
❖ Counsel the woman on specific aspects of postnatal care (See Normal delivery case sheet-Section 4).
It is important that the woman is made comfortable and approached in a friendly, respectful manner.
Based on the assessment done, information must be provided to the woman in simple and clear
language so that she would understand the message. When counselling it is important to remember
the following points for it to be effective:
-$■
Establish rapport or trust relationship with the woman;
Have conversations with a purpose;
Listen attentively to the woman's concerns;
❖
Helpthe woman to tell her story;
Give the woman correct and appropriate information;
Help the woman and her family to make informed decisions;
Help the woman to recognize and build on her strengths;
> Help the woman to develop a positive attitude to life;
.....
❖ A good way to checkif the woman has understood what was communicated is by asking her to repeat
the main points that were discussed. She could also be encouraged to ask questions so that her doubts
are cleared.
❖ Inform the woman that she must seek care urgently if she presents with any of the following at home
without delay:
-0- Vaginal bleeding
4*
Convulsions or fits
-$•
Severe headaches with blurred vision
Feverortoo weaktogetoutof bed
Severe abdominal
Fast or difficult breathing
❖ These flag a severe complication like either eclampsia, sepsis or PPH and thus would need
urgent attention.
The woman must also be informed to seek help as soon as possible for the following danger signs when
at home as they could reflect an infection which would need to be managed:
Fever
■0- Abdominal pain
Feel ill
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Skilled birth attendance care during labour, delivery and postnatal periods at 24/7 Primary Health Centres
Counsel on various aspects of care of newborn
❖ See details in Vol 3
Documentation
❖ All details related to discharge of woman and newborn are to be filled up in the outcomes sheet. The thayi
card if present must be completed by the staff nurse and duly signed.
6.4 Requirements to Manage Discharge
Equipments and supplies
Ensure that the following equipment is available at the PHC and in working condition:
❖ Blood pressure apparatus and stethoscope
❖ Thermometer
❖ Watch with seconds hand
❖ Disposable syringes and needles
❖ Polio vaccination
❖ TB vaccination
❖ Hepatitis B vaccination
❖ Family planning methods - IUCD, oral contraceptives, injectables, condoms
Clinical skills
In order to provide postnatal care select skills are required and these skills should be reviewed and focused
on if there is any difficulty in performing them. These skills include:
1. Monitoring vital signs including pulse, blood pressure, and temperature and pain (See CHAPTER 2 on
page #)
2. Monitoring of uterine tone, height, per vaginal bleeding, (See CHAPTER 3 on page 33)
3. Counselling skills (See CHAPTER 4, page 63)
4. Newborn assessment (See Vol 3 on page 47)
5. Documentation on the case sheet details of postnatal period (Section 4 OF CASE SHEET)
The clinical skills section provides detailed information on how to perform each of these procedures and could be
used as a resource when mentoring.
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6.5 Key Messages - Do's and Don'ts
DO monitor the woman and newborn closely in the first 48 hours postnatal. This is a
critical time period where many women and newborns develop complications and
die. Being alert helps diagnose complications early and ensure prompt access to
treatment.
DO show that you are listening to the woman during an interaction by facing or
looking at her when she speaks; nodding, showing appropriate facial expression,
being clam and patient
Do's
DO always counsel the woman and her family on the maternal and newborn danger
signs. Knowing when to seek care avoids delays in treatment and can save lives.
DO always counsel on general care, such as nutrition, family planning,
immunization and basic newborn care. Knowing how to stay healthy and prevent
illness is important.
DO vaccinate the newborn against hepatitis, polio and TB (BCG) before discharging
from the PHC. Vaccinations prevent illness and save newborn lives.
DO NOT ignore the woman and newborn in the 48 hours postnatal. This is an
important period where many mothers and newborns develop complications and die.
Being alert helps diagnose complications early and ensure prompt access to treatment.
DO NOT turn away during an interaction with the woman, and while she is talking
Don'ts
to you, don't do something else (writing notes, talking on the phone or doing some
other work or interrupt).
DO NOT tell or instruct the woman what to do during counselling, also not make
decisions on her behalf; don't judge, blame, preach to or argue with the mother;
don't make promises that could not be carried out, don't force your own belief
system on her.
Skilled birth attendance care during labour, delivery and postnatal periods at 24/7 Primary Health Centres
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Skilled birth attendance care during labour, delivery and postnatal periods at 24/7 Primary Health Cent
'
. >.:M.'
Use AMMA approach for PREPARATION for DISCHARGE
<♦ Assess the condition of the woman and baby before discharge, the
understanding of the woman and her family on the various aspects of care of
woman and child, the social and economic through exit interview.
<♦ Manage - Advise on postnatal care using the postnatal counselling checklist
in the case sheet and the educational material in the thayi card.
Agree on the aspects of postnatal care. Resolve conflicts if any especially
cultural issues like food taboos.
< Arrange for follow up (give a mutually convenient date and time)
arrange for transport if required. Follow up instructions and follow up
date needs to be given.
*
Assist with community level support and follow up by giving the contact
details of ASHA and informing the ASHA.
❖ Monitor
Audit the case sheet for completeness and follow up on all above steps to
see if it is completed in a timely manner.
<♦ Advocate
Once successful, discuss with other staff nurses in PHC and enourage
them also to adopt these steps in similar cases in the future.
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Bibliography
1. Dept of Health and Family Welfare (2010) National Rural Health Mission- Programme Implementation
Plan for 2010-2011. Govt of Karmataka.
2. Graham WJ, Cairns J, Bhattacharya S, Bullough CHW, Quayyum Z, Rogo K. Maternal and perinatal
conditions. In: Jamison DT, Breman JG, Measham AR, editors. Disease control priorities in developing
countries. 2nd ed. New York: Oxford University Press; 2006. p. 499-529.
3. Lawn JE, Zupan J, Begkoyian G, Knippenberg R. Newborn survival. In: Jamison DT, Breman JG, Measham
AR, editors. Disease control priorities in developing countries. 2nd ed. New York: Oxford University
Press; 2006. p. 531-549.
4. Maternal Health division, Ministry of Health and Family Welfare (2010) Guidelines for Antenatal Care
and Skilled Attendance at Birth by ANMs/LHVs/SNs. Government of India
5. Maternal Health Division, MoHFW (2008) Guidelines for Operationalising SBA Training in RCHI II- For
program managers. 1/C training institutions at state and district level. Government of India
6. Maternal Health Division, MoHFW (2010) . A Handbook for Auxilliary Nurse Midwives, Lady Health
Visitors and Staff Nurses. Gol
7. http://www.medtrng.com/blackboard/basic_nursing_assessment.htm
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Improved Maternal, Newborn & Child Health
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